Provider Demographics
NPI:1801355102
Name:GEORGER, DIANA M
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:GEORGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-3623
Mailing Address - Country:US
Mailing Address - Phone:323-314-2272
Mailing Address - Fax:
Practice Address - Street 1:6525 W SUNSET BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-7193
Practice Address - Country:US
Practice Address - Phone:323-314-2272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-16
Last Update Date:2019-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103606106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist