Provider Demographics
NPI:1578892683
Name:WILLIAMS, DIANE WITSON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:WITSON
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 1569
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-7569
Mailing Address - Country:US
Mailing Address - Phone:719-221-0654
Mailing Address - Fax:
Practice Address - Street 1:247 FOX CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:COALDALE
Practice Address - State:CO
Practice Address - Zip Code:81222-0023
Practice Address - Country:US
Practice Address - Phone:719-221-0654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2161103TC0700X
NM1119103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00870000OtherRR MEDICARE
NM77135822Medicaid
NM00870000OtherRR MEDICARE