Provider Demographics
NPI:1033313283
Name:BROWN, DIANE HAZELTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:HAZELTON
Last Name:BROWN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 SALINAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1642
Mailing Address - Country:US
Mailing Address - Phone:415-482-8000
Mailing Address - Fax:415-454-8612
Practice Address - Street 1:35 SALINAS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1642
Practice Address - Country:US
Practice Address - Phone:415-482-8000
Practice Address - Fax:415-454-8612
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16470103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY16470OtherLICENSE NUMBER
CAPSY16470OtherLICENSE NUMBER