Provider Demographics
NPI:1962504183
Name:MONTGOMERY-LOGAN, DIANE (MA)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:MONTGOMERY-LOGAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 HALL ST
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1738
Mailing Address - Country:US
Mailing Address - Phone:802-860-9500
Mailing Address - Fax:802-655-3963
Practice Address - Street 1:99 HALL ST
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1738
Practice Address - Country:US
Practice Address - Phone:802-860-9500
Practice Address - Fax:802-655-3963
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT534103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1004148Medicaid