Provider Demographics
NPI:1992000962
Name:AZEVEDO, MARISA
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:AZEVEDO
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 1:1039 CONTINENTALS WAY
Mailing Address - Street 2:106
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-3162
Mailing Address - Country:US
Mailing Address - Phone:831-566-1635
Mailing Address - Fax:
Practice Address - Street 1:957 INDUSTRIAL RD SUITE B
Practice Address - Street 2:EDGEWOOD FOR CHILDREN AND FAMILIES
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-4151
Practice Address - Country:US
Practice Address - Phone:415-375-7585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst