Basic Information
| Provider Information | |||||||||
| NPI: | 1477839850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | MARIE MICHELLE | ||||||||
| MiddleName: | MERCADO | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 654 N MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911011110 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 45111 FERN AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935342301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619491206 | ||||||||
| FaxNumber: | 6619405452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 10/28/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 56078 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.