Healthcare Provider Details

I. General information

NPI: 1710507694
Provider Name (Legal Business Name): DIAMANTINA LOCK LMFT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 POLLASKY AVE STE C
CLOVIS CA
93612-1159
US

IV. Provider business mailing address

PO BOX 2427
CLOVIS CA
93613-2427
US

V. Phone/Fax

Practice location:
  • Phone: 559-346-7127
  • Fax:
Mailing address:
  • Phone: 559-346-7127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DIAMANTINA LOCK
Title or Position: LMFT
Credential:
Phone: 559-346-7127