Provider Demographics
NPI:1396762043
Name:PALS, DIANA L (M ED)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:L
Last Name:PALS
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3049
Mailing Address - Country:US
Mailing Address - Phone:208-883-0619
Mailing Address - Fax:208-882-4774
Practice Address - Street 1:814 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3049
Practice Address - Country:US
Practice Address - Phone:208-883-0619
Practice Address - Fax:208-882-4774
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC -167101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID137333137335OtherPREMERA BLUE CROSS
ID000010015830OtherREGENCE BLUE SHIELD
IDQ107-5OtherBLUE CROSS OF IDAHO