Healthcare Provider Details

I. General information

NPI: 1114692522
Provider Name (Legal Business Name): DIANE MARIE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 CHICAGO AVE
RIVERSIDE CA
92507-2366
US

IV. Provider business mailing address

15225 MARIPOSA AVE
CHINO HILLS CA
91709-2713
US

V. Phone/Fax

Practice location:
  • Phone: 951-465-3664
  • Fax:
Mailing address:
  • Phone: 909-636-1918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number118216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: