Provider Demographics
NPI:1629735188
Name:IGNATOVICH, DIANA JANIE
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:JANIE
Last Name:IGNATOVICH
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 1:4282 N MARYLAND AVE
Mailing Address - Street 2:506
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217
Mailing Address - Country:US
Mailing Address - Phone:650-690-0787
Mailing Address - Fax:
Practice Address - Street 1:4282 N MARYLAND AVE
Practice Address - Street 2:506
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217
Practice Address - Country:US
Practice Address - Phone:650-690-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst