Healthcare Provider Details

I. General information

NPI: 1588964365
Provider Name (Legal Business Name): DIANE PEREZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6551 VAN NUYS BLVD STE 201
VAN NUYS CA
91401-1442
US

IV. Provider business mailing address

PO BOX 63087
LOS ANGELES CA
90063-0087
US

V. Phone/Fax

Practice location:
  • Phone: 818-988-6335
  • Fax: 818-988-6817
Mailing address:
  • Phone: 818-988-6335
  • Fax: 818-988-6817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: