MEDICARE: DIANA LYNN DIDUCK, PLLC

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1477001790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANA LYNN DIDUCK, PLLC

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

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

Authorized Official
Title or Position	:	MANAGER
Name	:	GERALD DIDUCK
Credential	:
Telephone Number	:	214-728-8006

Provider Enumeration Date	:	09/15/2016
Last Update Date	:	09/15/2016

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