Provider Demographics
NPI:1164731964
Name:PROSSER, DIANE BIRGIT (MFT)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:BIRGIT
Last Name:PROSSER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3604
Mailing Address - Country:US
Mailing Address - Phone:559-600-5946
Mailing Address - Fax:
Practice Address - Street 1:4411 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-5946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21767106H00000X
CA101YM0800X106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN4429037OtherDRIVERS LICENSE NUMBER