Provider Demographics
NPI:1235623547
Name:ORNELAS, MARLO
Entity type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:ORNELAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 WILLOW RD BLDG 332
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-2539
Mailing Address - Country:US
Mailing Address - Phone:650-324-1470
Mailing Address - Fax:650-324-4149
Practice Address - Street 1:795 WILLOW RD BLDG 332
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2539
Practice Address - Country:US
Practice Address - Phone:650-324-1470
Practice Address - Fax:650-324-4149
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2013388101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA010081ANOtherMEDICAL