Provider Demographics
NPI:1477094597
Name:CHAVEZ, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CHAVEZ
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 1:10929 SOUTH ST STE 208B
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-5391
Mailing Address - Country:US
Mailing Address - Phone:562-916-6408
Mailing Address - Fax:
Practice Address - Street 1:10929 SOUTH ST STE 208B
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-5391
Practice Address - Country:US
Practice Address - Phone:562-916-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA101YM0800X, 225400000X
CA102979101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner