Healthcare Provider Details

I. General information

NPI: 1649432451
Provider Name (Legal Business Name): DIANE EDEN, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35000 CHARDON RD 210
WILLOUGHBY OH
44094-9012
US

IV. Provider business mailing address

35000 CHARDON RD 210
WILLOUGHBY OH
44094-9012
US

V. Phone/Fax

Practice location:
  • Phone: 440-951-5600
  • Fax: 440-951-1293
Mailing address:
  • Phone: 440-951-5600
  • Fax: 440-951-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DIANE HOLLY EDEN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 440-951-5600