Provider Demographics
NPI:1497842298
Name:THOMPSON, DIANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:THOMPSON
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 1:1073 ENCANTADO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1076
Mailing Address - Country:US
Mailing Address - Phone:505-927-1727
Mailing Address - Fax:505-984-2908
Practice Address - Street 1:415 ONATE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-927-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM730103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00NM00JB65OtherBLUE CROSS BLUE SHIELD
NMNM100436OtherVALUE OPTIONS
NM15571076Medicaid