Provider Demographics
NPI:1689738841
Name:KAISER, DIANE S (PSYD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:KAISER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7720 NE HIGHWAY 99 STE D
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8859
Mailing Address - Country:US
Mailing Address - Phone:360-524-5200
Mailing Address - Fax:360-326-1635
Practice Address - Street 1:1701 E EVERGREEN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4289
Practice Address - Country:US
Practice Address - Phone:360-524-5200
Practice Address - Fax:360-326-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY2519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR164936Medicaid