Provider Demographics
NPI:1639163280
Name:TYRRELL, DIANE S (PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:TYRRELL
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 1:5500 MAIN ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-633-6900
Mailing Address - Fax:
Practice Address - Street 1:5500 MAIN ST
Practice Address - Street 2:SUITE 207
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-633-6900
Practice Address - Fax:716-633-6902
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009444-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000510515001OtherHEALTH NOW
NY000510515001OtherHEALTH NOW