Provider Demographics
NPI:1629396544
Name:SPEED, DIANE R (LMP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:R
Last Name:SPEED
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:R
Other - Last Name:VANRIPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1146 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3025
Mailing Address - Country:US
Mailing Address - Phone:360-577-6956
Mailing Address - Fax:
Practice Address - Street 1:1146 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3025
Practice Address - Country:US
Practice Address - Phone:360-577-6956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019704225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist