Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 106S00000X | Behavior Technician | 17-45543 | CA |
Y | 106S00000X | Behavior Technician | 1745543 | CA |
NPI | 1003319633 |
---|---|
Provider Name | Marissa Walten |
First Address | Pasadena, CA 91106-2380 |
Second Address | Stockton, CA 95207-5700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2018 |
Last Update Date | 06/07/2020 |