Provider Demographics
NPI:1417700204
Name:DIENER, MADISON JO
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:JO
Last Name:DIENER
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 1:61 DAYTON RD
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-9631
Mailing Address - Country:US
Mailing Address - Phone:509-515-6498
Mailing Address - Fax:
Practice Address - Street 1:61 DAYTON RD
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-9631
Practice Address - Country:US
Practice Address - Phone:509-515-6498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health