Provider Demographics
NPI:1386907962
Name:SORIANO, MARINE (MA)
Entity type:Individual
Prefix:
First Name:MARINE
Middle Name:
Last Name:SORIANO
Suffix:
Gender:F
Credentials:MA
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 79
Mailing Address - Street 2:
Mailing Address - City:CABAZON
Mailing Address - State:CA
Mailing Address - Zip Code:92230-0079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15455 SAN FERNANDO MISSION BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1353
Practice Address - Country:US
Practice Address - Phone:818-330-4782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF74862106H00000X
CA113241106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF74862OtherBOARD OF BEHAVIORAL SCIENCES
CALMFT113241OtherBOARD OF BEHAVIORAL SCIENCES