Provider Demographics
NPI:1952476913
Name:PEREZ, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PEREZ
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 1:14865 TACUBA DR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-2224
Mailing Address - Country:US
Mailing Address - Phone:213-430-6784
Mailing Address - Fax:
Practice Address - Street 1:529 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1511
Practice Address - Country:US
Practice Address - Phone:213-430-6784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALCSW645631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1512013461Medicaid
CA1512013461Medicare UPIN
CA1512013461Medicare ID - Type Unspecified