Healthcare Provider Details

I. General information

NPI: 1831427293
Provider Name (Legal Business Name): DIANE PUCHBAUER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 N EUCLID AVE
UPLAND CA
91786-6083
US

IV. Provider business mailing address

PO BOX 1570
UPLAND CA
91785-1570
US

V. Phone/Fax

Practice location:
  • Phone: 562-547-0137
  • Fax: 909-921-0221
Mailing address:
  • Phone: 562-547-0137
  • Fax: 909-921-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY21870
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number21870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: