Provider Demographics
NPI:1154917128
Name:SPIESS, DIANE E
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:E
Last Name:SPIESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:V911 STATE ROUTE 109
Mailing Address - Street 2:
Mailing Address - City:LIBERTY CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43532-8709
Mailing Address - Country:US
Mailing Address - Phone:419-270-6632
Mailing Address - Fax:
Practice Address - Street 1:V911 STATE ROUTE 109
Practice Address - Street 2:
Practice Address - City:LIBERTY CENTER
Practice Address - State:OH
Practice Address - Zip Code:43532-8709
Practice Address - Country:US
Practice Address - Phone:419-270-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3500689320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities