1609977263 NPI number — MRS. DIANE EILEEN CONKLIN LCSW

Table of content: MRS. DIANE EILEEN CONKLIN LCSW (NPI 1609977263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609977263 NPI number — MRS. DIANE EILEEN CONKLIN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONKLIN
Provider First Name:
DIANE
Provider Middle Name:
EILEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AUKLAND LCSW
Provider Other First Name:
DINAE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1609977263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
42525 RANCHO MIRAGE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO MIRAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92270-4312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-668-7665
Provider Business Mailing Address Fax Number:
760-832-8080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42525 RANCHO MIRAGE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANCHO MIRAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92270-4312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-776-6543
Provider Business Practice Location Address Fax Number:
760-776-6546
Provider Enumeration Date:
09/26/2006

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:  LCS 12169 , 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: LCS121690 . This is a "BLUESHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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