Provider Demographics
NPI:1194872952
Name:DERR LEWIS, DIANE M (PHD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:DERR LEWIS
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 74872
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:419-531-3500
Mailing Address - Fax:419-531-1877
Practice Address - Street 1:3425 EXECUTIVE PKWY
Practice Address - Street 2:SUITE 230
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1326
Practice Address - Country:US
Practice Address - Phone:419-531-3500
Practice Address - Fax:419-531-1877
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5384103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0911811Medicaid
OH03023OtherPARAMOUNT INDIVIDUAL PR
OH000000388012OtherANTHEM INDIVIDUAL PROV #
OH267100000OtherAETNA PROV #
OH0911811Medicaid