Provider Demographics
NPI:1336696574
Name:DAWSON, DIANA M
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:DAWSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FORRESTAL CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1914
Mailing Address - Country:US
Mailing Address - Phone:646-338-0531
Mailing Address - Fax:
Practice Address - Street 1:23 FORRESTAL CT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1914
Practice Address - Country:US
Practice Address - Phone:646-338-0531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1054727162103TS0200X
NJ1033066103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool