Healthcare Provider Details

I. General information

NPI: 1114973310
Provider Name (Legal Business Name): DIANE MARIE AGRESTA PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 S MAIN ST SUITE 209
ANN ARBOR MI
48104-2117
US

IV. Provider business mailing address

321 S MAIN ST SUITE 209
ANN ARBOR MI
48104-2117
US

V. Phone/Fax

Practice location:
  • Phone: 734-665-9890
  • Fax:
Mailing address:
  • Phone: 734-665-9890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301002761
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number6301002761
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301002761
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301002761
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301002761
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number6301002761
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number6301002761
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: