Provider Demographics
NPI:1720409220
Name:DIANA E MINER, PH.D, LLC
Entity Type:Organization
Organization Name:DIANA E MINER, PH.D, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-371-4434
Mailing Address - Street 1:181 POST RD W
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4626
Mailing Address - Country:US
Mailing Address - Phone:860-371-4434
Mailing Address - Fax:
Practice Address - Street 1:181 POST RD W
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4626
Practice Address - Country:US
Practice Address - Phone:860-371-4434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003120103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1396031738Medicare NSC