Basic Information
| Provider Information | |||||||||
| NPI: | 1821602855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROTSENKO | ||||||||
| FirstName: | MARINA | ||||||||
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| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 DOS RIOS ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958110442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168683963 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 HIGHWAY 104 | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2020 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 81518 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.