Provider Demographics
NPI:1417752809
Name:BARDALES, MARCY
Entity type:Individual
Prefix:
First Name:MARCY
Middle Name:
Last Name:BARDALES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12443 LEWIS ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4650
Mailing Address - Country:US
Mailing Address - Phone:714-707-2805
Mailing Address - Fax:
Practice Address - Street 1:12443 LEWIS ST STE 202
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4650
Practice Address - Country:US
Practice Address - Phone:714-707-2805
Practice Address - Fax:949-534-6756
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician