Provider Demographics
NPI:1649390741
Name:KLASSEN, DIANA CHRISTINA (MA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:CHRISTINA
Last Name:KLASSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1928 8TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-2712
Mailing Address - Country:US
Mailing Address - Phone:805-801-8994
Mailing Address - Fax:
Practice Address - Street 1:354 S HALCYON RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3876
Practice Address - Country:US
Practice Address - Phone:805-473-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT#87383106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSIX986Medicaid