Provider Demographics
NPI:1144722083
Name:NIETO, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:NIETO
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 1:16946 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3613
Mailing Address - Country:US
Mailing Address - Phone:888-320-1272
Mailing Address - Fax:855-978-6050
Practice Address - Street 1:32824 WOLF STORE RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-9672
Practice Address - Country:US
Practice Address - Phone:888-320-1272
Practice Address - Fax:855-978-6050
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT1617046106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician