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General NPI Number Information
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NPI Number | 1861693574
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Entity Type | Individual
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Provider Name | DIANE ELIZABETH SHROCK LMFT
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Gender | Female
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Dates
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Enumeration Date | 05/30/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 320 WESTERN AVE
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City | PETALUMA
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State | CA
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Zip | 94952-2919
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Country | US
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Telephone | 707-566-7712
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Fax | 707-829-3170
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Provider Business Mailing Address
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Address Line | 2817 CLAREMONT DR
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City | SANTA ROSA
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State | CA
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Zip | 95405-6868
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Country | US
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Telephone | 707-566-7123
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Fax | 707-829-3170
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC33832
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License Number State | CA
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