Provider Demographics
NPI:1568961613
Name:MASCARDO, MARNELLE (BA)
Entity Type:Individual
Prefix:
First Name:MARNELLE
Middle Name:
Last Name:MASCARDO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5318 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1810
Mailing Address - Country:US
Mailing Address - Phone:323-293-6291
Mailing Address - Fax:323-293-1091
Practice Address - Street 1:5318 S. CRENSHAW BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043
Practice Address - Country:US
Practice Address - Phone:323-293-6291
Practice Address - Fax:323-293-1091
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11055812OtherKAISER