Provider Demographics
NPI:1699216044
Name:VAN DIEPEN, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:VAN DIEPEN
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 1:5772 GARDEN GROVE BLVD
Mailing Address - Street 2:341A
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-1889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 GOODRICH BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022-5103
Practice Address - Country:US
Practice Address - Phone:657-549-1639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-18
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI3258101YP2500X
CAIMF95007106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional