Provider Demographics
NPI:1528674041
Name:FOSS, DIANNE DRAKE
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:DRAKE
Last Name:FOSS
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:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:GRAND LAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80447-0959
Mailing Address - Country:US
Mailing Address - Phone:303-921-5125
Mailing Address - Fax:
Practice Address - Street 1:THE INN AT SILVER CREEK
Practice Address - Street 2:62927 US-40
Practice Address - City:GRANBY, 80446
Practice Address - State:CO
Practice Address - Zip Code:80446
Practice Address - Country:US
Practice Address - Phone:303-921-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0011924103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty