Provider Demographics
NPI:1528132263
Name:DEKKER, DIANE LECLAIR SHAFER (PHD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LECLAIR SHAFER
Last Name:DEKKER
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 1:534 BLACK BEAR RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1816
Mailing Address - Country:US
Mailing Address - Phone:505-280-4295
Mailing Address - Fax:505-856-6764
Practice Address - Street 1:320 OSUNA RD NE
Practice Address - Street 2:SUITE H
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5952
Practice Address - Country:US
Practice Address - Phone:505-345-2778
Practice Address - Fax:505-345-2878
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM379103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000N7208Medicaid