Basic Information
| Provider Information | |||||||||
| NPI: | 1043522279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUEEN | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | DARYA | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | CLOVERDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954253204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078941801 | ||||||||
| FaxNumber: | 7078947820 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 TARMAN DR | ||||||||
| Address2: | |||||||||
| City: | CLOVERDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954253932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078944229 | ||||||||
| FaxNumber: | 7078942954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2010 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY 24787 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY24787 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.