Provider Demographics
NPI:1215987565
Name:LIST, DIANE (PHD, LP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LIST
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-1539
Mailing Address - Country:US
Mailing Address - Phone:989-672-6160
Mailing Address - Fax:989-672-5649
Practice Address - Street 1:443 N STATE ST
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-1539
Practice Address - Country:US
Practice Address - Phone:989-673-5700
Practice Address - Fax:989-672-2555
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006179103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN93280001Medicare PIN