Provider Demographics
NPI:1124146717
Name:HEARST IKEDA, DIANA (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:HEARST IKEDA
Suffix:
Gender:F
Credentials:PHD
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 2628
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02331-2628
Mailing Address - Country:US
Mailing Address - Phone:781-934-6390
Mailing Address - Fax:781-934-9991
Practice Address - Street 1:20 TREMONT ST
Practice Address - Street 2:SUITE 12 A
Practice Address - City:DUXBURY
Practice Address - State:MA
Practice Address - Zip Code:02332-5310
Practice Address - Country:US
Practice Address - Phone:781-934-6390
Practice Address - Fax:781-934-9991
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6917101YA0400X, 101YM0800X, 103T00000X, 103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05211Medicaid
MAW05611OtherBLUE CROSS BLUE SHIELD
MA407109OtherTUFTS BEHAVIORAL HEALTH
MAW05211Medicaid