Healthcare Provider Details

I. General information

NPI: 1003474818
Provider Name (Legal Business Name): DIANE MARIE MAZZONI MS, PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37479 AVENUE 12
MADERA CA
93636-8726
US

IV. Provider business mailing address

17549 ROAD 36 1/2
MADERA CA
93636-9207
US

V. Phone/Fax

Practice location:
  • Phone: 559-645-3572
  • Fax:
Mailing address:
  • Phone: 559-363-2583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: