Provider Demographics
NPI:1083165484
Name:WASHINGTON, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 W WESTWIND ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-6625
Mailing Address - Country:US
Mailing Address - Phone:909-219-3726
Mailing Address - Fax:
Practice Address - Street 1:1960 W WESTWIND ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6625
Practice Address - Country:US
Practice Address - Phone:909-219-3726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician