Provider Demographics
NPI:1114954674
Name:LATIMER, DIANE TRYON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:TRYON
Last Name:LATIMER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3843 ATTUCKS DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065
Mailing Address - Country:US
Mailing Address - Phone:614-553-7815
Mailing Address - Fax:
Practice Address - Street 1:3843 ATTUCKS DR.
Practice Address - Street 2:SUITE B
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065
Practice Address - Country:US
Practice Address - Phone:614-553-7815
Practice Address - Fax:336-834-0149
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2255103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000011Medicaid
NC0312LOtherBLUE CROSS BLUE SHIELD
NC120080OtherVALUEOPTIONS
NC2818319Medicare ID - Type Unspecified