1740312883 NPI number — MS. DIANA RUTH KRISHUN LCSW CBD

Table of content: MS. DIANA RUTH KRISHUN LCSW CBD (NPI 1740312883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740312883 NPI number — MS. DIANA RUTH KRISHUN LCSW CBD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRISHUN
Provider First Name:
DIANA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW CBD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRISHUN
Provider Other First Name:
DIANA
Provider Other Middle Name:
RUTH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW 523
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1740312883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26015 NARBONNE AVE
Provider Second Line Business Mailing Address:
SUITE 15
Provider Business Mailing Address City Name:
LOMITA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90717-3026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-345-4969
Provider Business Mailing Address Fax Number:
310-530-9475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 CRENSHAW BLVD
Provider Second Line Business Practice Location Address:
SUITE A-2
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-345-4969
Provider Business Practice Location Address Fax Number:
310-530-9475
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW 523 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCS 523 CBD9511 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11401259 . This is a "CAQH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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