=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013189216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA S. GREYWOLF PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2008
-----------------------------------------------------
Last Update Date | 02/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 ROUTE 5 S SUITE 1
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05055-9523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-649-2462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 124
-----------------------------------------------------
City | THETFORD
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05074-0124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-649-2462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 048.0051503
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------