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General NPI Number Information
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NPI Number | 1023168531
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Entity Type | Individual
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Provider Name | DIANE ALICIA TENNIES PH.D.
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Gender | Female
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 04/16/2013
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Provider Practice Location Address
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Address Line | 115 FRANKLIN ST SUITE 1A
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City | BANGOR
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State | ME
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Zip | 04401-4936
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Country | US
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Telephone | 207-942-3635
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Fax | 207-941-1933
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Provider Business Mailing Address
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Address Line | 115 FRANKLIN ST SUITE 1A
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City | BANGOR
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State | ME
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Zip | 04401-4936
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Country | US
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Telephone | 207-942-3635
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Fax | 207-941-1933
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | LC 1572
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 103TF0200X
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Taxonomy Name | Forensic Psychologist
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License Number | PS955
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License Number State | ME
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