Provider Demographics
NPI:1831427293
Name:PUCHBAUER, DIANE (PSYD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:PUCHBAUER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1570
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-1570
Mailing Address - Country:US
Mailing Address - Phone:562-547-0137
Mailing Address - Fax:909-921-0221
Practice Address - Street 1:188 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6083
Practice Address - Country:US
Practice Address - Phone:562-547-0137
Practice Address - Fax:909-921-0221
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21870103TF0000X
CA21870103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily