Provider Demographics
NPI:1659852853
Name:COELHO-SOUSAE, MARLENA LUCIA
Entity Type:Individual
Prefix:
First Name:MARLENA
Middle Name:LUCIA
Last Name:COELHO-SOUSAE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARLENA
Other - Middle Name:LUCIA
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:257 SELWYN DR APT A
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-5572
Mailing Address - Country:US
Mailing Address - Phone:530-205-7330
Mailing Address - Fax:
Practice Address - Street 1:1885 LUNDY AVE STE 223
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1888
Practice Address - Country:US
Practice Address - Phone:530-205-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid