Provider Demographics
NPI:1770079626
Name:KVASNICKA, MARION ANN ROSE (LCSW)
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:ANN ROSE
Last Name:KVASNICKA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4673 LOCH PL
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-2167
Mailing Address - Country:US
Mailing Address - Phone:530-921-5715
Mailing Address - Fax:
Practice Address - Street 1:4673 LOCH PL
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-2167
Practice Address - Country:US
Practice Address - Phone:530-921-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7980-S104100000X
CALCSW1105531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker