Provider Demographics
NPI:1891986741
Name:CLARK, DIANA MARIA
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:MARIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DIANA
Other - Middle Name:MARIA
Other - Last Name:MACEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT MS
Mailing Address - Street 1:18002 IRVINE BLVD STE 202F
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3322
Mailing Address - Country:US
Mailing Address - Phone:714-331-8477
Mailing Address - Fax:
Practice Address - Street 1:18002 IRVINE BLVD STE 202F
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3322
Practice Address - Country:US
Practice Address - Phone:657-205-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81829106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist