Provider Demographics
NPI:1174802474
Name:DVORAK, MARIKA KATHERINE
Entity type:Individual
Prefix:
First Name:MARIKA
Middle Name:KATHERINE
Last Name:DVORAK
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 1:1910 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-1220
Mailing Address - Country:US
Mailing Address - Phone:213-342-0100
Mailing Address - Fax:
Practice Address - Street 1:1910 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-1220
Practice Address - Country:US
Practice Address - Phone:213-342-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAAWS36306101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program