Provider Demographics
NPI:1194247593
Name:FICHTNER, MARIEJOSE BALLEZA (MFTI)
Entity type:Individual
Prefix:
First Name:MARIEJOSE
Middle Name:BALLEZA
Last Name:FICHTNER
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:MARIEJOSE
Other - Middle Name:BALLEZA
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3075 MYERS ST BLDG 1
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3075 MYERS ST BLDG 1
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5525
Practice Address - Country:US
Practice Address - Phone:951-358-6895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF93087106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist