Provider Demographics
NPI:1467425025
Name:SANBORN, DIANA (PHD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:SANBORN
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 1:1030 S. F. DRAKE BLVD.
Mailing Address - Street 2:SUITE 100-2
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1438
Mailing Address - Country:US
Mailing Address - Phone:415-721-2884
Mailing Address - Fax:415-482-6642
Practice Address - Street 1:1030 SF DRAKE BLVD
Practice Address - Street 2:SUITE 100-2
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1411
Practice Address - Country:US
Practice Address - Phone:415-721-2884
Practice Address - Fax:415-482-6642
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL150690Medicare ID - Type Unspecified