Provider Demographics
NPI:1376825364
Name:BINGHAM, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BINGHAM
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 1:464 N 300 E
Mailing Address - Street 2:BAMT
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4117
Mailing Address - Country:US
Mailing Address - Phone:208-650-8362
Mailing Address - Fax:
Practice Address - Street 1:464 N 300 E
Practice Address - Street 2:BASEMENT
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4117
Practice Address - Country:US
Practice Address - Phone:208-650-8362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist