Provider Demographics
NPI:1578579074
Name:DICUBELLIS, DIANE LUTZ (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LUTZ
Last Name:DICUBELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:7010 PHOENIX AVE NE APT 214
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3559
Mailing Address - Country:US
Mailing Address - Phone:505-720-6869
Mailing Address - Fax:
Practice Address - Street 1:8200 MOUNTAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7843
Practice Address - Country:US
Practice Address - Phone:505-830-6500
Practice Address - Fax:505-830-6527
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-063121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02322374Medicaid
NMNMB22221Medicare PIN