Provider Demographics
NPI:1255455564
Name:IVORY, DIANA (LMFT)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:IVORY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:MONTOYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1107 FAIR OAKS AVE # 85
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3311
Mailing Address - Country:US
Mailing Address - Phone:626-476-6658
Mailing Address - Fax:
Practice Address - Street 1:1188 N EUCLID ST STE 500
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1900
Practice Address - Country:US
Practice Address - Phone:714-644-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT52532106H00000X
CAIMF 49008106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist