Provider Demographics
NPI:1598981219
Name:PIERCE, DIANE KAYE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:KAYE
Last Name:PIERCE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 NW 22ND AVE
Mailing Address - Street 2:RIO 5-EAST
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3025
Mailing Address - Country:US
Mailing Address - Phone:503-413-6296
Mailing Address - Fax:503-413-8103
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:RIO 5-EAST
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-6296
Practice Address - Fax:503-413-8103
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR406103G00000X, 103TC0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR055103Medicaid
OR077404Medicaid
OR055103Medicaid
ORR94762Medicare UPIN