Provider Demographics
NPI:1073588505
Name:BADILLO MARTINEZ, DIANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:BADILLO MARTINEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 OLD NEW MILFORD RD
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2430
Mailing Address - Country:US
Mailing Address - Phone:203-775-5183
Mailing Address - Fax:203-775-8453
Practice Address - Street 1:60 OLD NEW MILFORD RD
Practice Address - Street 2:SUITE 3D
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2430
Practice Address - Country:US
Practice Address - Phone:203-775-5183
Practice Address - Fax:203-775-8453
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1212103G00000X, 103T00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069084Medicaid
CT620000208Medicare ID - Type Unspecified