Provider Demographics
NPI:1275631939
Name:TREBILCOCK, DIANE BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:BETH
Last Name:TREBILCOCK
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 1:2911 EYDE PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823
Mailing Address - Country:US
Mailing Address - Phone:517-324-1284
Mailing Address - Fax:
Practice Address - Street 1:2911 EYDE PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-324-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007023103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M91560Medicare ID - Type Unspecified