Provider Demographics
NPI:1588238489
Name:LIZCANO, DIANA (PSYD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:LIZCANO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:LIZCANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:55 LOCK ST FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LOCK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3603
Practice Address - Country:US
Practice Address - Phone:203-432-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003481103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical