Provider Demographics
NPI:1750522652
Name:ESTRADA, DIANE
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:ESTRADA
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-0030
Mailing Address - Country:US
Mailing Address - Phone:707-422-0464
Mailing Address - Fax:707-422-0465
Practice Address - Street 1:1049 UNION AVE STE D
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5526
Practice Address - Country:US
Practice Address - Phone:707-422-0464
Practice Address - Fax:707-422-0465
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA48BI1Medicaid