Provider Demographics
NPI:1396386355
Name:GUARDADO, MARISA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:GUARDADO
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 1:3680 17TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2632
Mailing Address - Country:US
Mailing Address - Phone:415-225-6956
Mailing Address - Fax:
Practice Address - Street 1:1640 VALENCIA ST STE 2A
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-5040
Practice Address - Country:US
Practice Address - Phone:415-225-6956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA278171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10.0.0.232Medicaid