Provider Demographics
NPI:1063059160
Name:IRIAS, MARYEM (MFTA)
Entity type:Individual
Prefix:MRS
First Name:MARYEM
Middle Name:
Last Name:IRIAS
Suffix:
Gender:F
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4708
Mailing Address - Country:US
Mailing Address - Phone:626-272-3921
Mailing Address - Fax:
Practice Address - Street 1:3611 SENECA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1820
Practice Address - Country:US
Practice Address - Phone:626-272-3921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103792101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health