Provider Demographics
NPI:1255043360
Name:KRUCK, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KRUCK
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 1:3152 CATAWBA DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-7973
Mailing Address - Country:US
Mailing Address - Phone:530-409-5617
Mailing Address - Fax:
Practice Address - Street 1:3152 CATAWBA DR
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-7973
Practice Address - Country:US
Practice Address - Phone:530-409-5617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA155428106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist