Provider Demographics
NPI:1700145141
Name:CHAN, DIANA M (PSYD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:CHAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:CHAN
Other - Last Name:KAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:4199 CAMPUS DR
Mailing Address - Street 2:SUITE 550
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-4684
Mailing Address - Country:US
Mailing Address - Phone:949-391-3658
Mailing Address - Fax:
Practice Address - Street 1:4199 CAMPUS DR
Practice Address - Street 2:SUITE 550
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-4684
Practice Address - Country:US
Practice Address - Phone:949-391-3658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical