Provider Demographics
NPI:1942973805
Name:KLEBANOV, MARIANNA (MFT AND LPCC)
Entity Type:Individual
Prefix:
First Name:MARIANNA
Middle Name:
Last Name:KLEBANOV
Suffix:
Gender:F
Credentials:MFT AND LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MIDDLEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1625
Mailing Address - Country:US
Mailing Address - Phone:650-425-3644
Mailing Address - Fax:
Practice Address - Street 1:1303 SAN CARLOS AVE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2317
Practice Address - Country:US
Practice Address - Phone:650-425-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 101YM0800X, 261QM0801X
CA138005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)