Provider Demographics
NPI:1841755154
Name:DIEDERICK, SARAH E
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:E
Last Name:DIEDERICK
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 1:125 BAKER ST UNIT 253
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4562
Mailing Address - Country:US
Mailing Address - Phone:502-599-6239
Mailing Address - Fax:
Practice Address - Street 1:23151 VERDUGO DR STE 113
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1340
Practice Address - Country:US
Practice Address - Phone:949-954-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician