Provider Demographics
NPI:1629391867
Name:MERCER, DIANE CAROLYN
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CAROLYN
Last Name:MERCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16850 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5794
Mailing Address - Country:US
Mailing Address - Phone:760-241-8000
Mailing Address - Fax:760-962-8021
Practice Address - Street 1:16850 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5794
Practice Address - Country:US
Practice Address - Phone:760-241-8000
Practice Address - Fax:760-962-8021
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP9906235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare Oscar/Certification