Provider Demographics
NPI:1063540656
Name:PLUMMER, DIANE (SW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PLUMMER
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SOLAR RD NW
Mailing Address - Street 2:ALVARADO ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5754
Mailing Address - Country:US
Mailing Address - Phone:505-344-4412
Mailing Address - Fax:
Practice Address - Street 1:1100 SOLAR RD NW
Practice Address - Street 2:ALVARADO ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5754
Practice Address - Country:US
Practice Address - Phone:505-344-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 2155104100000X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH 3205Medicaid