Provider Demographics
NPI:1396857322
Name:WHITEHEAD, DIANE LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LOUISE
Last Name:WHITEHEAD
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:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:607 BAXTER ST
Practice Address - Street 2:FAIRVIEW ASS.
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-232-2670
Practice Address - Fax:423-928-0381
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPHD 425103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
119750OtherANTHEM PROF TRIGON
334969OtherVALUEOPTIONS (GROUP)
0106607OtherMAGELLAN SUMMIT
119750OtherANTHEM PREFTRIGON
TN3980891Medicaid
0106607OtherMAGELLAN PINNACLE
0106607OtherMAGELLAN NAVIGATOR
TN3689293Medicaid
7692240OtherAETNA
7692240OtherAETNA
0106607OtherMAGELLAN PINNACLE