MEDICARE: DR. ELLEN M DIANA PH.D.

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	1968	AZ

General Provider Information

NPI Number	:	1255416509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN M DIANA PH.D.

Provider Business Mailing Address
First Line	:	2509 E RIDGE CREEK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-5274
Country	:	US
Telephone Number	:	480-703-0037
Fax Number	:

Provider Business Practice Location Address
First Line	:	2509 E RIDGE CREEK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-5274
Country	:	US
Telephone Number	:	480-703-0037
Fax Number	:

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	10/22/2010

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