Provider Demographics
NPI:1649793209
Name:GERONIMO, DIANA LORENE (LMFT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LORENE
Last Name:GERONIMO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3192
Mailing Address - Country:US
Mailing Address - Phone:541-790-9261
Mailing Address - Fax:541-357-7102
Practice Address - Street 1:400 E 2ND AVE STE 104E
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2452
Practice Address - Country:US
Practice Address - Phone:541-357-7502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1526106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist