Provider Demographics
NPI:1780790485
Name:IRVING, DIANA ROSE (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:ROSE
Last Name:IRVING
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MRS
Other - First Name:DIANA
Other - Middle Name:ROSE
Other - Last Name:EDGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:P. O. BOX 1296
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-1934
Mailing Address - Country:US
Mailing Address - Phone:951-392-0632
Mailing Address - Fax:888-850-7657
Practice Address - Street 1:126 AVOCADO AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-392-0632
Practice Address - Fax:888-850-7657
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 110541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHR2892OtherMEDICARE PTAN