Provider Demographics
NPI:1851696009
Name:POLAK-GOMEZ, DIANE KAY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:KAY
Last Name:POLAK-GOMEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 PARKVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-1768
Mailing Address - Country:US
Mailing Address - Phone:909-706-2740
Mailing Address - Fax:909-591-8736
Practice Address - Street 1:2275 PARKVIEW LN
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-1768
Practice Address - Country:US
Practice Address - Phone:909-706-2740
Practice Address - Fax:909-591-8736
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS159181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical