Provider Demographics
NPI:1831473727
Name:ESCOFFON, DIANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:ESCOFFON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-0106
Mailing Address - Country:US
Mailing Address - Phone:650-483-8991
Mailing Address - Fax:
Practice Address - Street 1:1001 BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2649
Practice Address - Country:US
Practice Address - Phone:209-256-1998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18636103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist