Provider Demographics
NPI:1114939311
Name:DIEGO, DOREEN ANN (MA, MFT INTERN)
Entity Type:Individual
Prefix:MS
First Name:DOREEN
Middle Name:ANN
Last Name:DIEGO
Suffix:
Gender:F
Credentials:MA, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 POWER INN RD STE 180
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3889
Mailing Address - Country:US
Mailing Address - Phone:916-876-5434
Mailing Address - Fax:
Practice Address - Street 1:3331 POWER INN RD STE 180
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3889
Practice Address - Country:US
Practice Address - Phone:916-876-5434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 44207106H00000X
CA49016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114939311Medicaid