Healthcare Provider Details

I. General information

NPI: 1184296964
Provider Name (Legal Business Name): DIEDRA LEE AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 S 41ST ST APT 6
SAN DIEGO CA
92113-3379
US

IV. Provider business mailing address

PO BOX 151112
SAN DIEGO CA
92175-1112
US

V. Phone/Fax

Practice location:
  • Phone: 619-316-9301
  • Fax:
Mailing address:
  • Phone: 619-895-7993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number210176024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: