Provider Demographics
NPI:1275146847
Name:RADILLA, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RADILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 16TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-3606
Mailing Address - Country:US
Mailing Address - Phone:510-860-2239
Mailing Address - Fax:
Practice Address - Street 1:8945 GOLF LINKS RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-4124
Practice Address - Country:US
Practice Address - Phone:510-317-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133990106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist