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General NPI Number Information
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NPI Number | 1184296964
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Entity Type | Individual
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Provider Name | DIEDRA LEE AMFT
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Gender | Female
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Dates
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Enumeration Date | 07/12/2021
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Last Update Date | 04/05/2024
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Provider Practice Location Address
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Address Line | 1061 S 41ST ST APT 6
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City | SAN DIEGO
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State | CA
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Zip | 92113-3379
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Country | US
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Telephone | 619-316-9301
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 151112
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City | SAN DIEGO
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State | CA
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Zip | 92175-1112
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Country | US
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Telephone | 619-895-7993
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 110576
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 110576
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number |
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | CA
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