Healthcare Provider Details

I. General information

NPI: 1144578758
Provider Name (Legal Business Name): DIANA CUELLO PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 PIERCE ST SUITE 305
KINGSTON PA
18704-5512
US

IV. Provider business mailing address

480 PIERCE ST SUITE 305
KINGSTON PA
18704-5512
US

V. Phone/Fax

Practice location:
  • Phone: 570-437-0558
  • Fax: 570-714-9444
Mailing address:
  • Phone: 570-437-0558
  • Fax: 570-714-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS017248
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: