Provider Demographics
NPI:1710591664
Name:DE LIRA ASTORGA, MARCELA
Entity Type:Individual
Prefix:
First Name:MARCELA
Middle Name:
Last Name:DE LIRA ASTORGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 LAKE TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2580 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7727
Practice Address - Country:US
Practice Address - Phone:530-544-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAASW1115341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health