Provider Demographics
NPI:1164662011
Name:PISAN, DIANE MARIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:PISAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 WOODBINE RD
Mailing Address - Street 2:APT 6
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-4017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:977 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-7406
Practice Address - Country:US
Practice Address - Phone:781-891-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist