Provider Demographics
NPI:1912927666
Name:COULTER, DIANA W (MFT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:W
Last Name:COULTER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 VIA VERDE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4400
Mailing Address - Country:US
Mailing Address - Phone:909-599-8800
Mailing Address - Fax:909-599-6661
Practice Address - Street 1:1115 VIA VERDE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-4400
Practice Address - Country:US
Practice Address - Phone:909-599-8800
Practice Address - Fax:909-599-6661
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC17759106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist