Provider Demographics
NPI:1093874281
Name:DIANA, THOMAS LEO (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEO
Last Name:DIANA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3478
Mailing Address - Country:US
Mailing Address - Phone:507-452-1021
Mailing Address - Fax:507-452-1504
Practice Address - Street 1:66 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3478
Practice Address - Country:US
Practice Address - Phone:507-452-1021
Practice Address - Fax:507-452-1504
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1219103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN731291041000OtherPREFERRED ONE
MN126921OtherUCARE
MN200048200Medicaid
MN78G63DIOtherBCBS-MN
MNHP41036OtherHEALTHPARTNERS
MN200048200Medicaid