Provider Demographics
NPI:1639525264
Name:PRIVITT, DIANNA RENEE
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:RENEE
Last Name:PRIVITT
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 1:8131 MARSEILLE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6017
Mailing Address - Country:US
Mailing Address - Phone:714-625-9527
Mailing Address - Fax:
Practice Address - Street 1:155 N OCCIDENTAL BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4641
Practice Address - Country:US
Practice Address - Phone:213-381-2931
Practice Address - Fax:213-381-0884
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF101130106H00000X
390200000X
CAAMFT101130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program