Provider Demographics
NPI:1447601083
Name:NILSSON, DIANE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:NILSSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MEDICAL DR STE 122
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4956
Mailing Address - Country:US
Mailing Address - Phone:385-275-0492
Mailing Address - Fax:385-275-6764
Practice Address - Street 1:425 MEDICAL DR STE 122
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4956
Practice Address - Country:US
Practice Address - Phone:385-275-0492
Practice Address - Fax:385-275-6764
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3261344102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist