Provider Demographics
NPI:1396311247
Name:VAN DIEN, HALEY THELMA (BA)
Entity type:Individual
Prefix:MISS
First Name:HALEY
Middle Name:THELMA
Last Name:VAN DIEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15188 LAVERDA LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-4099
Mailing Address - Country:US
Mailing Address - Phone:951-505-9749
Mailing Address - Fax:
Practice Address - Street 1:15188 LAVERDA LN
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-4099
Practice Address - Country:US
Practice Address - Phone:951-505-9749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician