Provider Demographics
NPI:1912159914
Name:CAUGHLIN, DIANA NICOLE (MA)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:NICOLE
Last Name:CAUGHLIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:DIANA
Other - Middle Name:NICOLE
Other - Last Name:ENSIGN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11622 EL CAMINO REAL STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2051
Mailing Address - Country:US
Mailing Address - Phone:619-549-0329
Mailing Address - Fax:
Practice Address - Street 1:11622 EL CAMINO REAL STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2051
Practice Address - Country:US
Practice Address - Phone:619-549-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105856106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist