Provider Demographics
NPI:1184060154
Name:CHANG, MARISA (MS, BCBA)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 COZZOLINO DR
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-1301
Mailing Address - Country:US
Mailing Address - Phone:415-722-1718
Mailing Address - Fax:
Practice Address - Street 1:37 COZZOLINO DR
Practice Address - Street 2:
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-1301
Practice Address - Country:US
Practice Address - Phone:415-722-1718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-9615103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst