Provider Demographics
NPI:1174831598
Name:MARROQUIN, GERSON ENRIQUE
Entity type:Individual
Prefix:MR
First Name:GERSON
Middle Name:ENRIQUE
Last Name:MARROQUIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9540 CENTER AVE.
Mailing Address - Street 2:STE 100
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9540 CENTER AVE
Practice Address - Street 2:STE 100
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5840
Practice Address - Country:US
Practice Address - Phone:909-728-2638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor