Provider Demographics
NPI:1013148469
Name:PRIETO DE ESTEBECORENA, MARIA JOSE (PH,D)
Entity Type:Individual
Prefix:
First Name:MARIA JOSE
Middle Name:
Last Name:PRIETO DE ESTEBECORENA
Suffix:
Gender:F
Credentials:PH,D
Other - Prefix:
Other - First Name:MARIA JOSE
Other - Middle Name:
Other - Last Name:ESTEBECORENA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2154 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2694
Mailing Address - Country:US
Mailing Address - Phone:415-457-3451
Mailing Address - Fax:415-457-3819
Practice Address - Street 1:2154 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2694
Practice Address - Country:US
Practice Address - Phone:415-457-3451
Practice Address - Fax:415-457-3819
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22819103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist