Provider Demographics
NPI:1346596491
Name:DIMOND, DIANE STAVROPOULOS (MA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:STAVROPOULOS
Last Name:DIMOND
Suffix:
Gender:F
Credentials:MA
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 1722
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-4722
Mailing Address - Country:US
Mailing Address - Phone:707-419-1683
Mailing Address - Fax:
Practice Address - Street 1:821 E 2ND ST STE 201F
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-3344
Practice Address - Country:US
Practice Address - Phone:707-419-1683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 52086106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist