Provider Demographics
NPI:1962168112
Name:MONTANEZ, MARISSA BERNICE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:BERNICE
Last Name:MONTANEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 LAYTON ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-2619
Mailing Address - Country:US
Mailing Address - Phone:909-948-5414
Mailing Address - Fax:
Practice Address - Street 1:6117 BROCKTON AVE STE 202
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2207
Practice Address - Country:US
Practice Address - Phone:951-440-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst