Provider Demographics
NPI:1811973662
Name:YOUNG, DIANE DUCHON (PHD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:DUCHON
Last Name:YOUNG
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 1:593 EDDY ST
Mailing Address - Street 2:POTTER 3
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-6573
Practice Address - Street 1:146 W RIVER ST
Practice Address - Street 2:SUITE 11B
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2609
Practice Address - Country:US
Practice Address - Phone:401-444-7442
Practice Address - Fax:401-444-7109
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00635103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
007009002Medicare ID - Type Unspecified
P64759Medicare UPIN