Basic Information
| Provider Information | |||||||||
| NPI: | 1750756425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NERSISYAN | ||||||||
| FirstName: | MARINE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | AYDINDZHYAN | ||||||||
| OtherFirstName: | MARINE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 S SANTA ANITA AVE | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910063536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
| FaxNumber: | 6262941077 | ||||||||
| Practice Location | |||||||||
| Address1: | 237 N CENTRAL AVE | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912032531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185479544 | ||||||||
| FaxNumber: | 8185499041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2015 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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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 | 99420 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.