Provider Demographics
NPI:1902464209
Name:NORTHNESS, DIANA (AMFT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:NORTHNESS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 LONGBRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 MCMILLAN AVE STE 108
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6765
Practice Address - Country:US
Practice Address - Phone:805-781-4948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110394106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist