Provider Demographics
NPI:1568511475
Name:ANDERSON, DIANNE L (PHD)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:LR
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:55 1ST PL NW
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-3271
Mailing Address - Country:US
Mailing Address - Phone:425-394-0301
Mailing Address - Fax:425-394-0287
Practice Address - Street 1:55 1ST PL NW
Practice Address - Street 2:SUITE 4
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3271
Practice Address - Country:US
Practice Address - Phone:425-394-0301
Practice Address - Fax:425-394-0287
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002455103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAN8462OtherREGENCE PIN
7675082OtherAETNA US HEALTHCARE PIN