Provider Demographics
NPI:1083371124
Name:DANILUKE, MARCIE JOSEPHINE (R138711040)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:JOSEPHINE
Last Name:DANILUKE
Suffix:
Gender:F
Credentials:R138711040
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 CONCORD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2862
Mailing Address - Country:US
Mailing Address - Phone:408-849-8656
Mailing Address - Fax:
Practice Address - Street 1:102 S 11TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-2132
Practice Address - Country:US
Practice Address - Phone:408-998-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR138711040101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)