Healthcare Provider Details

I. General information

NPI: 1447068507
Provider Name (Legal Business Name): DIANE ELIZABETH CAUDILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 CALIFORNIA ST
EUREKA CA
95501-2808
US

IV. Provider business mailing address

PO BOX 7381
EUREKA CA
95502-7381
US

V. Phone/Fax

Practice location:
  • Phone: 707-443-7358
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number140066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: