Provider Demographics
NPI:1689798035
Name:BRODERSEN EPPLER, DIANE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:BRODERSEN EPPLER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 MARGIT ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4742
Mailing Address - Country:US
Mailing Address - Phone:909-528-0850
Mailing Address - Fax:
Practice Address - Street 1:420 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4610
Practice Address - Country:US
Practice Address - Phone:909-307-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 17235106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist