Basic Information
| Provider Information | |||||||||
| NPI: | 1003149279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRICHILO | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., ABPDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2795 | ||||||||
| Address2: | |||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954732795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078241130 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 PITT AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954723747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078241130 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2009 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY 16784 | CA | N | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | PSY 16784 | CA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.