Provider Demographics
NPI:1649282450
Name:SUFFRIDGE, DIANE A (PHD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:SUFFRIDGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 NORTHGATE DR
Mailing Address - Street 2:FAMILY SERVICE AGENCY OF MARIN
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3680
Mailing Address - Country:US
Mailing Address - Phone:415-491-5708
Mailing Address - Fax:
Practice Address - Street 1:555 NORTHGATE DR
Practice Address - Street 2:FAMILY SERVICE AGENCY OF MARIN
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3680
Practice Address - Country:US
Practice Address - Phone:415-491-5708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10707103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL107070Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER