Provider Demographics
NPI:1255693461
Name:BAILEY-TUDER, DIANA (CMT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BAILEY-TUDER
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2813 VIA MONTECITO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3623
Mailing Address - Country:US
Mailing Address - Phone:949-303-8233
Mailing Address - Fax:
Practice Address - Street 1:149 AVENIDA GRANADA FL 2
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4055
Practice Address - Country:US
Practice Address - Phone:949-303-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25001174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator