Provider Demographics
NPI:1093462384
Name:BORROMEO, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BORROMEO
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 1:1510 FASHION ISLAND BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94404-5043
Mailing Address - Country:US
Mailing Address - Phone:415-964-7690
Mailing Address - Fax:
Practice Address - Street 1:1510 FASHION ISLAND BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94404-5043
Practice Address - Country:US
Practice Address - Phone:415-964-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14901101YP2500X
CA142068106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABACB765676OtherBACB ID