Doctor Name: | LEA DARYA QUEEN |
NPI Number: | 1043522279 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PSY.D |
License Number: | PSY 24787 |
Business Practice Address: | 6 Tarman Dr Cloverdale, CA - 954253932 |
Business Phone Number: | 7078944229 |
Business Fax Number: | 7078942954 |
Mailing Address: | 100 W 3rd St, CLOVERDALE |
State: | CA |
Postal Code: | 954253204 |
Phone Number: | 7078941801 |
Fax Number: | 7078947820 |
NPI Enumeration Date: | 07/02/2010 |
NPI Last Update Date: | 01/23/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | PSY 24787 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | CA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |