Provider Demographics
NPI:1609977263
Name:CONKLIN, DIANE EILEEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:EILEEN
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:DINAE
Other - Middle Name:
Other - Last Name:AUKLAND LCSW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:42525 RANCHO MIRAGE LN
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4312
Mailing Address - Country:US
Mailing Address - Phone:760-668-7665
Mailing Address - Fax:760-832-8080
Practice Address - Street 1:42525 RANCHO MIRAGE LN
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4312
Practice Address - Country:US
Practice Address - Phone:760-776-6543
Practice Address - Fax:760-776-6546
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 121691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS121690OtherBLUESHIELD PIN
CAZZZ35210ZMedicare ID - Type UnspecifiedMEDICARE
CAR65269Medicare UPIN