Provider Demographics
NPI:1508955907
Name:CRISMAN, DIANE R (MAT CCC-SP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:R
Last Name:CRISMAN
Suffix:
Gender:F
Credentials:MAT CCC-SP
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 D
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:IN
Mailing Address - Zip Code:46737-0774
Mailing Address - Country:US
Mailing Address - Phone:260-495-9098
Mailing Address - Fax:
Practice Address - Street 1:401 SOUTH BROAD ST., SUITE A
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:IN
Practice Address - Zip Code:46737-0774
Practice Address - Country:US
Practice Address - Phone:260-495-9098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22000997A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist