Provider Demographics
NPI:1972531473
Name:BREAN, DIANA (SL)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BREAN
Suffix:
Gender:F
Credentials:SL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:MONONGAHELA
Mailing Address - State:PA
Mailing Address - Zip Code:15063-1553
Mailing Address - Country:US
Mailing Address - Phone:724-258-6211
Mailing Address - Fax:724-258-6225
Practice Address - Street 1:1027 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MONONGAHELA
Practice Address - State:PA
Practice Address - Zip Code:15063-1553
Practice Address - Country:US
Practice Address - Phone:724-258-6211
Practice Address - Fax:724-258-6225
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL002963L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016749970001Medicaid
PA0016749970001Medicaid