Healthcare Provider Details

I. General information

NPI: 1447373493
Provider Name (Legal Business Name): MARIVIC ROSABELLE DIZON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 EUREKA SQ SUITE 213
PACIFICA CA
94044-2654
US

IV. Provider business mailing address

80 EUREKA SQ SUITE 213
PACIFICA CA
94044-2654
US

V. Phone/Fax

Practice location:
  • Phone: 650-355-0841
  • Fax: 650-268-9646
Mailing address:
  • Phone: 650-355-0841
  • Fax: 650-268-9646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY 22893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: