Provider Demographics
NPI:1235200791
Name:FELTON, DIANE KAY (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:KAY
Last Name:FELTON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:KAY
Other - Last Name:SANDRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6120 EARLE BROWN DR
Mailing Address - Street 2:SUITE 520
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2123
Mailing Address - Country:US
Mailing Address - Phone:763-531-0566
Mailing Address - Fax:763-531-0602
Practice Address - Street 1:6120 EARLE BROWN DR
Practice Address - Street 2:SUITE 520
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2123
Practice Address - Country:US
Practice Address - Phone:763-531-0566
Practice Address - Fax:763-531-0602
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1489103TC0700X, 103TC2200X, 103TF0200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4H026FEOtherBLUECROSSBLUESHIELD
MN61-12600OtherMEDICA
MN104655OtherUCARE
MNHP35175OtherHEALTHPARTNERS
MN193852500Medicaid