Provider Demographics
NPI:1407399637
Name:DIZON, RAYNALD
Entity Type:Individual
Prefix:
First Name:RAYNALD
Middle Name:
Last Name:DIZON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 VALDORA ST
Mailing Address - Street 2:APT. 112
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-6341
Mailing Address - Country:US
Mailing Address - Phone:510-862-6646
Mailing Address - Fax:
Practice Address - Street 1:1540 VALDORA ST
Practice Address - Street 2:APT. 112
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-6341
Practice Address - Country:US
Practice Address - Phone:510-862-6646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-20
Last Update Date:2016-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician