Provider Demographics
NPI:1053823385
Name:FADDIS, KAREN DIEGA
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:DIEGA
Last Name:FADDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:DIEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 N JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020
Mailing Address - Country:US
Mailing Address - Phone:619-440-4801
Mailing Address - Fax:619-442-1592
Practice Address - Street 1:1365 N JOHNSON AVE STE 111
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:619-440-4801
Practice Address - Fax:619-442-1592
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)