Provider Demographics
NPI:1790455194
Name:PEMBERTON, DIANE L
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:PEMBERTON
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 1:135 WIANNO AVE
Mailing Address - Street 2:
Mailing Address - City:OSTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02655-1925
Mailing Address - Country:US
Mailing Address - Phone:508-360-6267
Mailing Address - Fax:
Practice Address - Street 1:135 WIANNO AVE
Practice Address - Street 2:
Practice Address - City:OSTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02655-1925
Practice Address - Country:US
Practice Address - Phone:508-360-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health