Provider Demographics
NPI:1114162047
Name:DIANE, SALLY (EDD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:DIANE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42525 RANCHO MIRAGE LN
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4312
Mailing Address - Country:US
Mailing Address - Phone:760-777-0167
Mailing Address - Fax:
Practice Address - Street 1:79100 KRISTEN CT
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7205
Practice Address - Country:US
Practice Address - Phone:760-777-0167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 44515106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist