MEDICARE: DIANA DIDUCK M.S., BCBA, LPC-I

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	101YP2500X	Professional Counselor	74979	TX
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1336695246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA DIDUCK M.S., BCBA, LPC-I

Provider Business Mailing Address
First Line	:	4555 ELSBY AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75209-3113
Country	:	US
Telephone Number	:	214-728-9485
Fax Number	:

Provider Business Practice Location Address
First Line	:	8100 LOMO ALTO DR
Second Line	:	SUITE 100
City	:	DALLAS
State	:	TX
Zip	:	75225-6530
Country	:	US
Telephone Number	:	214-351-0053
Fax Number	:

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

Provider Enumeration Date	:	08/30/2016
Last Update Date	:	09/13/2016

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