Healthcare Provider Details

I. General information

NPI: 1801768007
Provider Name (Legal Business Name): MARIAFE TEVI PANIZO JANSANA DR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIELDS AVE RM 219
DAVIS CA
95616-8500
US

IV. Provider business mailing address

1 SHIELDS AVE RM 219
DAVIS CA
95616-8500
US

V. Phone/Fax

Practice location:
  • Phone: 540-752-0871
  • Fax:
Mailing address:
  • Phone: 540-752-0871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSY34262
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: