Provider Demographics
NPI:1144006065
Name:PEREIDA, MARISSA CONSUELO ANGELINA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:CONSUELO ANGELINA
Last Name:PEREIDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94927-1247
Mailing Address - Country:US
Mailing Address - Phone:707-477-4673
Mailing Address - Fax:
Practice Address - Street 1:1968 S COAST HWY # 634
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-3681
Practice Address - Country:US
Practice Address - Phone:619-547-1856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist