Provider Demographics
NPI:1063988293
Name:DIFFNER, COURTNEY (LCSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DIFFNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:MICKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31815 CAMINO CAPISTRANO STE 28
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3231
Mailing Address - Country:US
Mailing Address - Phone:949-632-6625
Mailing Address - Fax:949-493-1555
Practice Address - Street 1:31815 CAMINO CAPISTRANO STE 28
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3231
Practice Address - Country:US
Practice Address - Phone:949-632-6625
Practice Address - Fax:949-493-1555
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical