Provider Demographics
NPI:1245357763
Name:PICAZO, CONNIE MARIELA (MA)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIELA
Last Name:PICAZO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5356 MAKATI CIR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-6248
Mailing Address - Country:US
Mailing Address - Phone:408-391-3664
Mailing Address - Fax:
Practice Address - Street 1:777 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6337
Practice Address - Country:US
Practice Address - Phone:408-240-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI: 64256106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist