Provider Demographics
NPI:1083768402
Name:ELLIOTT, DIANE CASANUEVA (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:CASANUEVA
Last Name:ELLIOTT
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 1:277 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2419
Mailing Address - Country:US
Mailing Address - Phone:478-755-0060
Mailing Address - Fax:478-743-3508
Practice Address - Street 1:277 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2419
Practice Address - Country:US
Practice Address - Phone:478-755-0060
Practice Address - Fax:478-743-3508
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPST000800103TC2200X
GAPSY003112103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA556624291AMedicaid
GA68BBGTQMedicare PIN