Provider Demographics
NPI:1225241821
Name:STEPHENS, DIANE LESLIE (MFT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LESLIE
Last Name:STEPHENS
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 1:917 RUGBY LN
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-1838
Mailing Address - Country:US
Mailing Address - Phone:209-521-1714
Mailing Address - Fax:209-522-5700
Practice Address - Street 1:819 15TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1113
Practice Address - Country:US
Practice Address - Phone:209-521-1714
Practice Address - Fax:209-522-5700
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 30129106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist