Provider Demographics
NPI:1942341847
Name:BACKUS, DIANE WADIAK (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:WADIAK
Last Name:BACKUS
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 1:1012 SW EMKAY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1010
Mailing Address - Country:US
Mailing Address - Phone:541-617-0024
Mailing Address - Fax:
Practice Address - Street 1:1012 SW EMKAY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1010
Practice Address - Country:US
Practice Address - Phone:541-617-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1468103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR808489000OtherREGENCE BLUE CROSS BLUE S