Provider Demographics
NPI:1851916423
Name:DUZAK, MARY ELISE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELISE
Last Name:DUZAK
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 1:298A BERNAL ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119
Mailing Address - Country:US
Mailing Address - Phone:408-780-0755
Mailing Address - Fax:
Practice Address - Street 1:298A BERNAL ROAD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119
Practice Address - Country:US
Practice Address - Phone:408-780-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1399920820106S00000X, 101YA0400X
AZT064283183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No183700000XPharmacy Service ProvidersPharmacy Technician