Provider Demographics
NPI:1326304734
Name:DUDEK, DIANE KATHRYN (AMFT, CADC-II, ICADC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:KATHRYN
Last Name:DUDEK
Suffix:
Gender:F
Credentials:AMFT, CADC-II, ICADC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:KATHRYN
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC-II, ICADC
Mailing Address - Street 1:1278 N EASTBURY AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1481
Mailing Address - Country:US
Mailing Address - Phone:951-710-4156
Mailing Address - Fax:
Practice Address - Street 1:1278 N EASTBURY AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1481
Practice Address - Country:US
Practice Address - Phone:951-710-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA05190315101YA0400X
CAAMFT152296106H00000X
CAI9841210225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
A05190315OtherCALIFORNIA CONSORTIUM OF ADDICTION PROGRAMS AND PROFESSIONALS
CAAMFT152296OtherSTATE OF CALIFORNIA BOARD OF BEHAVIORAL SCIENCES