Provider Demographics
NPI:1043522279
Name:QUEEN, LEA DARYA (PSYD)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:DARYA
Last Name:QUEEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3204
Mailing Address - Country:US
Mailing Address - Phone:707-894-1801
Mailing Address - Fax:707-894-7820
Practice Address - Street 1:6 TARMAN DR
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-3932
Practice Address - Country:US
Practice Address - Phone:707-894-4229
Practice Address - Fax:707-894-2954
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24787103TC0700X
CAPSY24787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical