Healthcare Provider Details

I. General information

NPI: 1265671283
Provider Name (Legal Business Name): DIANA MARIE REPKE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2009
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 9930A WEST JOHNSON ST
TACOMA WA
98431-1100
US

IV. Provider business mailing address

9940 JACKSON AVENUE
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-5906
  • Fax:
Mailing address:
  • Phone: 253-968-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY3594
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY3594
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: