Healthcare Provider Details

I. General information

NPI: 1902187594
Provider Name (Legal Business Name): AMY LYNN MARSELINE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 E SAN FERNANDO ST
SAN JOSE CA
95112-3503
US

IV. Provider business mailing address

195 E SAN FERNANDO ST
SAN JOSE CA
95112-3503
US

V. Phone/Fax

Practice location:
  • Phone: 408-899-7149
  • Fax: 408-514-2384
Mailing address:
  • Phone: 408-899-7149
  • Fax: 408-514-2384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: