Provider Demographics
NPI:1164552667
Name:KOENEN, DIANA SUZANNE (MA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:SUZANNE
Last Name:KOENEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MINTHORN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530
Mailing Address - Country:US
Mailing Address - Phone:951-245-3207
Mailing Address - Fax:951-487-2679
Practice Address - Street 1:SUN PLAZA BUSINESS CENTER
Practice Address - Street 2:27851 BRADLEY RD, SUITE 103
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586
Practice Address - Country:US
Practice Address - Phone:951-575-8729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34961106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist