Provider Demographics
NPI:1811487937
Name:KETTERMAN, DIANA PATRICIA (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:PATRICIA
Last Name:KETTERMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:P
Other - Last Name:KETTERMAN-NAJERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:5033 CARRIAGE RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-1685
Mailing Address - Country:US
Mailing Address - Phone:909-732-6224
Mailing Address - Fax:909-980-4789
Practice Address - Street 1:5033 CARRIAGE RD
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91737-1685
Practice Address - Country:US
Practice Address - Phone:909-732-6224
Practice Address - Fax:909-980-4789
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2551103TS0200X
CA33769103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty