Healthcare Provider Details

I. General information

NPI: 1194525493
Provider Name (Legal Business Name): DIANE PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12810 HEACOCK ST STE B202
MORENO VALLEY CA
92553-2873
US

IV. Provider business mailing address

9800 NEWVILLE AVE
DOWNEY CA
90240-3530
US

V. Phone/Fax

Practice location:
  • Phone: 951-247-6542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: