Provider Demographics
NPI:1477515476
Name:REISER, DIANE (LPHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:REISER
Suffix:
Gender:F
Credentials:LPHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2612
Mailing Address - Country:US
Mailing Address - Phone:970-494-4300
Mailing Address - Fax:970-494-4301
Practice Address - Street 1:525 W OAK ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2612
Practice Address - Country:US
Practice Address - Phone:970-494-4300
Practice Address - Fax:970-494-4301
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2877103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC806588Medicare PIN