MEDICARE: MARIA JOSE PRIETO DE ESTEBECORENA PH,D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PSY22819	CA
2	103T00000X	Psychologist	PSY22819	CA

General Provider Information

NPI Number	:	1013148469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA JOSE PRIETO DE ESTEBECORENA PH,D.

Provider Business Mailing Address
First Line	:	2154 4TH ST
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-2694
Country	:	US
Telephone Number	:	415-457-3451
Fax Number	:	415-457-3819

Provider Business Practice Location Address
First Line	:	2154 4TH ST
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-2694
Country	:	US
Telephone Number	:	415-457-3451
Fax Number	:	415-457-3819

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2009
Last Update Date	:	03/14/2011

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