Provider Demographics
NPI:1669136537
Name:CONCANNON, DIANA M (PSYD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:M
Last Name:CONCANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:409 N PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2870
Mailing Address - Country:US
Mailing Address - Phone:310-625-8483
Mailing Address - Fax:
Practice Address - Street 1:23430 HAWTHORNE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4732
Practice Address - Country:US
Practice Address - Phone:310-625-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019686103T00000X
UT8109380-2501103T00000X
DCPSY10000763103T00000X
DCPSY1000763103T00000X
CAPSY22106103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist