Provider Demographics
NPI:1447373493
Name:DIZON, MARIVIC ROSABELLE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIVIC
Middle Name:ROSABELLE
Last Name:DIZON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 EUREKA SQ
Mailing Address - Street 2:SUITE 213
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2654
Mailing Address - Country:US
Mailing Address - Phone:650-355-0841
Mailing Address - Fax:650-268-9646
Practice Address - Street 1:80 EUREKA SQ
Practice Address - Street 2:SUITE 213
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-2654
Practice Address - Country:US
Practice Address - Phone:650-355-0841
Practice Address - Fax:650-268-9646
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22893103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent