Provider Demographics
NPI:1760667406
Name:DACOSTE, MARCY JOHN
Entity Type:Individual
Prefix:MR
First Name:MARCY
Middle Name:JOHN
Last Name:DACOSTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CHUMALIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4545
Mailing Address - Country:US
Mailing Address - Phone:510-595-2567
Mailing Address - Fax:
Practice Address - Street 1:25 CHUMALIA ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4545
Practice Address - Country:US
Practice Address - Phone:510-595-2567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34471041C0700X
CA5617106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist