Provider Demographics
NPI:1346247830
Name:OSBORNE, DIANA (PHD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:OSBORNE
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 1:11104 PARKVIEW CIRCLE DR
Mailing Address - Street 2:STE 110
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1730
Mailing Address - Country:US
Mailing Address - Phone:260-460-3203
Mailing Address - Fax:260-460-3130
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR
Practice Address - Street 2:STE 110
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-460-3203
Practice Address - Fax:260-460-3130
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040538A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN860000041OtherRR MEDICARE
OH0968921Medicaid
IN200040220Medicaid
IN148730BMedicare PIN
IN5506830003Medicare NSC
IN860000041OtherRR MEDICARE
R33702Medicare UPIN
OH0968921Medicaid