Provider Demographics
NPI:1164983540
Name:RUFINO, MARY JOSSA GRACE
Entity Type:Individual
Prefix:
First Name:MARY JOSSA GRACE
Middle Name:
Last Name:RUFINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 FAIRBURN WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-5034
Mailing Address - Country:US
Mailing Address - Phone:209-298-5092
Mailing Address - Fax:
Practice Address - Street 1:1140 LA MESA ST
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-1682
Practice Address - Country:US
Practice Address - Phone:209-298-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-31524103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst