Provider Demographics
NPI:1710022884
Name:SHIBUYA, MARIA-LUANNA BOZZOLO
Entity Type:Individual
Prefix:
First Name:MARIA-LUANNA
Middle Name:BOZZOLO
Last Name:SHIBUYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA-LUANNA
Other - Middle Name:LUCIA
Other - Last Name:BOZZOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5174 NORTH VIA DE LA LANZA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-7077
Mailing Address - Country:US
Mailing Address - Phone:520-615-2115
Mailing Address - Fax:
Practice Address - Street 1:5174 N VIA DE LA LANZA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-7077
Practice Address - Country:US
Practice Address - Phone:520-615-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3626103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical