Provider Demographics
NPI:1093699472
Name:MARISCAL, MIYA
Entity type:Individual
Prefix:
First Name:MIYA
Middle Name:
Last Name:MARISCAL
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 ONEONTA AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3431
Mailing Address - Country:US
Mailing Address - Phone:619-933-4375
Mailing Address - Fax:
Practice Address - Street 1:1550 HOTEL CIR N STE 270
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2908
Practice Address - Country:US
Practice Address - Phone:619-782-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-25-458296106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician