Healthcare Provider Details

I. General information

NPI: 1275017709
Provider Name (Legal Business Name): MARIAM CISSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 ARLINGTON DR
SAN LEANDRO CA
94578-1132
US

IV. Provider business mailing address

2275 ARLINGTON DR
SAN LEANDRO CA
94578-1132
US

V. Phone/Fax

Practice location:
  • Phone: 510-317-1444
  • Fax:
Mailing address:
  • Phone: 510-317-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number92806
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number92806
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: