Provider Demographics
NPI:1568471936
Name:SHOLTZ, DIANA (PHD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:SHOLTZ
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:P.O. BOX 29
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654
Mailing Address - Country:US
Mailing Address - Phone:207-255-4990
Mailing Address - Fax:207-255-8748
Practice Address - Street 1:1 STACKPOLE ROAD
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654
Practice Address - Country:US
Practice Address - Phone:207-255-0996
Practice Address - Fax:207-255-8748
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000858103TC0700X
MEPS1236103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN3783Medicaid
ME432800499Medicaid
VTVN3783Medicare PIN