Provider Demographics
NPI:1841418753
Name:VICIOSO, EMILY ANN
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:VICIOSO
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 1:299 12TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-6003
Mailing Address - Country:US
Mailing Address - Phone:831-647-7652
Mailing Address - Fax:
Practice Address - Street 1:299 12TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-6003
Practice Address - Country:US
Practice Address - Phone:831-647-7652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB7565610OtherDRIVER'S LICENSE
CA27BW8OtherMEDI-CAL PRV NBR
CA44CFOtherMEDI-CAL PRV NBR