Healthcare Provider Details

I. General information

NPI: 1942129150
Provider Name (Legal Business Name): PATRICIA ANNE MARCELENO SP 23052
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2881-B PAMELA LANE
CLEARLAKE OAKS CA
95423
US

IV. Provider business mailing address

PO BOX 24
LOWER LAKE CA
95457-0024
US

V. Phone/Fax

Practice location:
  • Phone: 707-217-3555
  • Fax:
Mailing address:
  • Phone: 707-217-3555
  • Fax: 707-377-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number23052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: