Provider Demographics
NPI:1760948384
Name:EVANGELISA, MARISSA E
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:E
Last Name:EVANGELISA
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 1:4512 MACKINAW ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-5920
Mailing Address - Country:US
Mailing Address - Phone:510-364-6265
Mailing Address - Fax:
Practice Address - Street 1:4512 MACKINAW ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-5920
Practice Address - Country:US
Practice Address - Phone:510-364-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
0469578OtherKAISER