Healthcare Provider Details

I. General information

NPI: 1407117062
Provider Name (Legal Business Name): KARLA DIESTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. KARLA MENJIVAR

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 HOPE ST STE 350
SOUTH PASADENA CA
91030-2658
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105-2711
US

V. Phone/Fax

Practice location:
  • Phone: 626-414-5606
  • Fax: 626-737-6034
Mailing address:
  • Phone: 323-543-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number76463
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number117050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: