MEDICARE: DR. DIANE J COHEN CARLSON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY13662	CA
2	103T00000X	Psychologist	PSY13662	CA

General Provider Information

NPI Number	:	1871575308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE J COHEN CARLSON PHD

Provider Business Mailing Address
First Line	:	5625 COLLEGE AVE STE 210C
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94618-1677
Country	:	US
Telephone Number	:	510-653-1464
Fax Number	:	510-547-0174

Provider Business Practice Location Address
First Line	:	5625 COLLEGE AVE STE 210C
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94618-1677
Country	:	US
Telephone Number	:	510-653-1464
Fax Number	:	510-547-0174

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	12/02/2024

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