Provider Demographics
NPI:1063973162
Name:MEZA, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MEZA
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 1:9190 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-4126
Mailing Address - Country:US
Mailing Address - Phone:809-268-0716
Mailing Address - Fax:
Practice Address - Street 1:9190 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701-4126
Practice Address - Country:US
Practice Address - Phone:909-268-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83893104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker