Provider Demographics
NPI:1225083090
Name:TODD, DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:TODD
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 1:57950 LEAVENWORTH ST
Mailing Address - Street 2:22D MEDICAL GROUP
Mailing Address - City:MCCONNELL AFB
Mailing Address - State:KS
Mailing Address - Zip Code:67221-3506
Mailing Address - Country:US
Mailing Address - Phone:316-759-5091
Mailing Address - Fax:316-759-1304
Practice Address - Street 1:57950 LEAVENWORTH ST
Practice Address - Street 2:22D MEDICAL GROUP
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-5091
Practice Address - Fax:316-759-1304
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS119707Medicare ID - Type Unspecified
S69236Medicare UPIN