Healthcare Provider Details

I. General information

NPI: 1063639524
Provider Name (Legal Business Name): DIANE MYERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S IDAHO ST STE 250
LA HABRA CA
90631-6594
US

IV. Provider business mailing address

501 S IDAHO ST STE 100
LA HABRA CA
90631-6047
US

V. Phone/Fax

Practice location:
  • Phone: 562-690-0400
  • Fax: 562-690-3182
Mailing address:
  • Phone: 562-690-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-01466
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54144
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number961
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY01796
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW001771
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: