Provider Demographics
NPI:1801557384
Name:HULBERT, MARISSA M
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:M
Last Name:HULBERT
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 1:555 N PERRIS BLVD BLDG A
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2811
Mailing Address - Country:US
Mailing Address - Phone:951-436-5300
Mailing Address - Fax:
Practice Address - Street 1:1330 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3905
Practice Address - Country:US
Practice Address - Phone:909-580-3705
Practice Address - Fax:909-580-3747
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128362106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist