MEDICARE: DIANA LYNN SPRING MALLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6361004181	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0995781	OTHER	MI	HEALTHPLUS
2	P108958490	OTHER	MI	BCBS
3	6224176	OTHER		DBH

General Provider Information

NPI Number	:	1003800889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA LYNN SPRING MALLP

Provider Business Mailing Address
First Line	:	PO BOX 772263
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48277-0428
Country	:	US
Telephone Number	:	989-494-4613
Fax Number	:	248-605-3525

Provider Business Practice Location Address
First Line	:	2127 UNIVERSITY PARK DR STE 300
Second Line	:
City	:	OKEMOS
State	:	MI
Zip	:	48864-5928
Country	:	US
Telephone Number	:	517-705-3667
Fax Number	:	248-605-3525

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	08/07/2022

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Directions to “ DIANA LYNN SPRING MALLP” Practice Location

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