Provider Demographics
NPI:1083835383
Name:STEGBAUER, DIANNE M (MA)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:M
Last Name:STEGBAUER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:M
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MC
Mailing Address - Street 1:9735 WALLINGFORD AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3525
Mailing Address - Country:US
Mailing Address - Phone:206-478-9749
Mailing Address - Fax:
Practice Address - Street 1:9735 WALLINGFORD AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-3525
Practice Address - Country:US
Practice Address - Phone:206-478-9749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006770101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH00006770OtherWASHINGTON STATE LICENSURE
WA0007911917OtherAETNA PROVIDER