Healthcare Provider Details

I. General information

NPI: 1952517138
Provider Name (Legal Business Name): DIANA KOTTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 NORTHGATE DR FAMILY SERVICE AGENCY OF MARIN
SAN RAFAEL CA
94903-3680
US

IV. Provider business mailing address

555 NORTHGATE DR FAMILY SERVICE AGENCY OF MARIN
SAN RAFAEL CA
94903-3680
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-5700
  • Fax:
Mailing address:
  • Phone: 415-491-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF 52904
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: