Provider Demographics
NPI:1194755769
Name:LIPSON, DIANE ROTH (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ROTH
Last Name:LIPSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 TOWNSGATE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VLG
Mailing Address - State:CA
Mailing Address - Zip Code:91361-3015
Mailing Address - Country:US
Mailing Address - Phone:818-707-7709
Mailing Address - Fax:
Practice Address - Street 1:2829 TOWNSGATE RD STE 100
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-3015
Practice Address - Country:US
Practice Address - Phone:818-707-7709
Practice Address - Fax:818-707-7759
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR34105Medicare PIN