Provider Demographics
NPI:1699347294
Name:HARTEL, MARISSA (MA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HARTEL
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 1:101 N INDIAN HILL BLVD STE C1-200
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4667
Mailing Address - Country:US
Mailing Address - Phone:866-200-9090
Mailing Address - Fax:909-503-0603
Practice Address - Street 1:101 N INDIAN HILL BLVD STE C1-200
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4667
Practice Address - Country:US
Practice Address - Phone:866-200-9090
Practice Address - Fax:909-503-0603
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94026057390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSB94026057OtherREGISTERED INTERN NUMBER