Provider Demographics
NPI:1063861391
Name:ACEVEDO MANZO, MARLENE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:ACEVEDO MANZO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SCOFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-7515
Mailing Address - Country:US
Mailing Address - Phone:562-308-6749
Mailing Address - Fax:
Practice Address - Street 1:701 SCOFIELD AVE
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-7515
Practice Address - Country:US
Practice Address - Phone:562-308-6749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW78236104100000X
CA978291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker