Basic Information
| Provider Information | |||||||||
| NPI: | 1568593101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDERO | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11738 MAGNOLIA BLVD APT 3 | ||||||||
| Address2: | |||||||||
| City: | VALLEY VILLAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916075604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186453659 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12450 VAN NUYS BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913311391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188968366 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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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 | 225400000X | IMF47546 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | MFC 47090 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.