Provider Demographics
NPI:1831516731
Name:MARZOLINO, STACI BLAIR (LCSW, BCBA)
Entity type:Individual
Prefix:MS
First Name:STACI
Middle Name:BLAIR
Last Name:MARZOLINO
Suffix:
Gender:F
Credentials:LCSW, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BIRCH CT
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-5720
Mailing Address - Country:US
Mailing Address - Phone:856-520-3099
Mailing Address - Fax:
Practice Address - Street 1:306 WESTWOOD OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5108
Practice Address - Country:US
Practice Address - Phone:856-520-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040079461041C0700X
VA0133000637103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical