Provider Demographics
NPI:1619213774
Name:BORNEMAN, DIANE H (PSYCHOLOGIST)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:H
Last Name:BORNEMAN
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 S LAKE DOSTER DR
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9109
Mailing Address - Country:US
Mailing Address - Phone:269-664-3066
Mailing Address - Fax:
Practice Address - Street 1:3299 GULL RD.
Practice Address - Street 2:1ST W 3RD FL
Practice Address - City:NAZARETH
Practice Address - State:MI
Practice Address - Zip Code:49074-0063
Practice Address - Country:US
Practice Address - Phone:269-553-8060
Practice Address - Fax:269-553-8104
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008718103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist