Provider Demographics
NPI:1013517697
Name:SHAFF, MARISA DAWN
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:DAWN
Last Name:SHAFF
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 1:1167 ROSITA RD
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-4221
Mailing Address - Country:US
Mailing Address - Phone:650-235-5908
Mailing Address - Fax:
Practice Address - Street 1:424 PENINSULA AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1653
Practice Address - Country:US
Practice Address - Phone:650-286-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-20-134143106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician