Provider Demographics
NPI:1770677700
Name:TREVISANO, MARNE ANN (EDD PHD LICENSED PSY)
Entity Type:Individual
Prefix:DR
First Name:MARNE
Middle Name:ANN
Last Name:TREVISANO
Suffix:
Gender:F
Credentials:EDD PHD LICENSED PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-1149
Mailing Address - Country:US
Mailing Address - Phone:805-462-8025
Mailing Address - Fax:805-462-8025
Practice Address - Street 1:5801 TRAFFIC WAY
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4253
Practice Address - Country:US
Practice Address - Phone:805-462-8025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9162103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4164833Medicaid
CA4164833Medicaid