Provider Demographics
NPI:1134683063
Name:ALYSSA MARIE WELLNESS, INC
Entity Type:Organization
Organization Name:ALYSSA MARIE WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCAO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-461-0408
Mailing Address - Street 1:15300 VENTURA BLVD STE 509
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-5812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15300 VENTURA BLVD STE 509
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-5812
Practice Address - Country:US
Practice Address - Phone:909-461-0408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty