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General NPI Number Information
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NPI Number | 1760667406
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Entity Type | Individual
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Provider Name | MR. MARCY JOHN DACOSTE
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Gender | Male
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Dates
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Enumeration Date | 12/31/2007
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Last Update Date | 12/31/2007
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Provider Practice Location Address
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Address Line | 25 CHUMALIA ST
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City | SAN LEANDRO
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State | CA
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Zip | 94577-4545
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Country | US
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Telephone | 510-595-2567
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Fax |
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Provider Business Mailing Address
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Address Line | 25 CHUMALIA ST
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City | SAN LEANDRO
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State | CA
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Zip | 94577-4545
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Country | US
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Telephone | 510-595-2567
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 3447
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 5617
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License Number State | CA
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