Provider Demographics
NPI:1417001983
Name:BOLL, DIANE MARIE (PSY D)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:BOLL
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 RIMPAU AVE SUITE 104
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879
Mailing Address - Country:US
Mailing Address - Phone:951-377-2138
Mailing Address - Fax:
Practice Address - Street 1:710 RIMPAU AVE SUITE 104
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879
Practice Address - Country:US
Practice Address - Phone:951-377-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17101103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical