Provider Demographics
NPI:1003474818
Name:MAZZONI, DIANE MARIE (MS, PPS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:MAZZONI
Suffix:
Gender:F
Credentials:MS, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17549 ROAD 36 1/2
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-9207
Mailing Address - Country:US
Mailing Address - Phone:559-363-2583
Mailing Address - Fax:
Practice Address - Street 1:37479 AVENUE 12
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8726
Practice Address - Country:US
Practice Address - Phone:559-645-3572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2326103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA91-2129526OtherMEDI-CAL