Provider Demographics
NPI:1962783951
Name:PACIFICA NEUROPSYCHOLOGY CENTER
Entity type:Organization
Organization Name:PACIFICA NEUROPSYCHOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-547-0084
Mailing Address - Street 1:461 W 6TH ST, SUITE 211
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2694
Mailing Address - Country:US
Mailing Address - Phone:310-547-0084
Mailing Address - Fax:310-833-5672
Practice Address - Street 1:461 W 6TH ST, SUITE 211
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2694
Practice Address - Country:US
Practice Address - Phone:310-547-0084
Practice Address - Fax:310-833-5672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19781103G00000X
CAMFC 42200106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty