Provider Demographics
NPI:1497139661
Name:BUENROSTRO, MARCENA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARCENA
Middle Name:
Last Name:BUENROSTRO
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 1:2629 CLARENDON AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4119
Mailing Address - Country:US
Mailing Address - Phone:323-584-3700
Mailing Address - Fax:
Practice Address - Street 1:2629 CLARENDON AVE FL 2
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4119
Practice Address - Country:US
Practice Address - Phone:323-584-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW71837101YM0800X
390200000X
CALCSW943731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program