Provider Demographics
NPI:1518092279
Name:DAMRON, DIANE ELLYN
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELLYN
Last Name:DAMRON
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 1:162 E CARSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-2866
Mailing Address - Country:US
Mailing Address - Phone:583-045-8052
Mailing Address - Fax:530-458-7751
Practice Address - Street 1:162 E CARSON ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2866
Practice Address - Country:US
Practice Address - Phone:583-045-8052
Practice Address - Fax:530-458-7751
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18811106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist