Provider Demographics
NPI:1114055456
Name:MARCUCCI, PAMELA (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:MARCUCCI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 NORTHGATE DR STE 480
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2542
Mailing Address - Country:US
Mailing Address - Phone:415-456-2975
Mailing Address - Fax:
Practice Address - Street 1:1050 NORTHGATE DR STE 480
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2542
Practice Address - Country:US
Practice Address - Phone:415-456-2975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19108103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL191080Medicare ID - Type UnspecifiedMEDICARE