Basic Information
| Provider Information | |||||||||
| NPI: | 1801557384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HULBERT | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 N PERRIS BLVD BLDG A | ||||||||
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| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925712811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514365300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1330 E COOLEY DR | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803705 | ||||||||
| FaxNumber: | 9095803747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2022 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 128362 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.