Provider Demographics
NPI:1033530274
Name:VICKERMAN, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:VICKERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5222
Mailing Address - Street 2:
Mailing Address - City:BEAR VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95223-5222
Mailing Address - Country:US
Mailing Address - Phone:209-890-7717
Mailing Address - Fax:
Practice Address - Street 1:891 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9713
Practice Address - Country:US
Practice Address - Phone:209-890-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health