Individual
EMILY ANN VICIOSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
299 12TH ST, SUITE A, MARINA, CA 93933-6003
(831) 647-7652
Mailing address
299 12TH ST, SUITE A, MARINA, CA 93933-6003
(831) 647-7652
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
27BW8
MEDI-CAL PRV NBR
CA
01
—
44CF
MEDI-CAL PRV NBR
CA
01
—
B7565610
DRIVER'S LICENSE
CA
Enumeration date
04/23/2007
Last updated
09/12/2016
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