Provider Demographics
NPI:1962288373
Name:PERRY, MARISA ROMANO (LEP 2872)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:ROMANO
Last Name:PERRY
Suffix:
Gender:F
Credentials:LEP 2872
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12611 SAN VICENTE BLVD # 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4915
Mailing Address - Country:US
Mailing Address - Phone:310-387-5342
Mailing Address - Fax:
Practice Address - Street 1:12611 SAN VICENTE BLVD # 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4915
Practice Address - Country:US
Practice Address - Phone:310-387-5342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2872103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral