Provider Demographics
NPI:1225110380
Name:SMITH, DIANE M (MFT)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:SMITH
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:PO BOX 1706
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-0706
Mailing Address - Country:US
Mailing Address - Phone:714-997-5384
Mailing Address - Fax:
Practice Address - Street 1:16960 BASTANCHURY RD
Practice Address - Street 2:SUITE J
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-1711
Practice Address - Country:US
Practice Address - Phone:714-449-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 33630106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 33630OtherMARRIAGE AND FAMILY LICEN