Basic Information
| Provider Information | |||||||||
| NPI: | 1164552667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOENEN | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1400 MINTHORN AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512453207 | ||||||||
| FaxNumber: | 9514872679 | ||||||||
| Practice Location | |||||||||
| Address1: | SUN PLAZA BUSINESS CENTER | ||||||||
| Address2: | 27851 BRADLEY RD, SUITE 103 | ||||||||
| City: | MENIFEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515758729 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC34961 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.