Healthcare Provider Details

I. General information

NPI: 1912159914
Provider Name (Legal Business Name): DIANA NICOLE CAUGHLIN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. DIANA NICOLE ENSIGN

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11622 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-2051
US

IV. Provider business mailing address

11622 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-2051
US

V. Phone/Fax

Practice location:
  • Phone: 619-549-0329
  • Fax:
Mailing address:
  • Phone: 619-549-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105856
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: