Provider Demographics
NPI:1285853473
Name:MINK, DIANE LESLIE (PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LESLIE
Last Name:MINK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 SAN VINCENTE BLVD
Mailing Address - Street 2:STE 900
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:310-826-1085
Mailing Address - Fax:310-479-3450
Practice Address - Street 1:11980 SAN VINCENTE BLVD
Practice Address - Street 2:STE 900
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049
Practice Address - Country:US
Practice Address - Phone:310-826-1085
Practice Address - Fax:310-479-3450
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY123800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical