Provider Demographics
NPI:1023264728
Name:BALL, DIANE CORA
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:CORA
Last Name:BALL
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 1:521 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1649
Mailing Address - Country:US
Mailing Address - Phone:510-663-7313
Mailing Address - Fax:510-663-5908
Practice Address - Street 1:521 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1649
Practice Address - Country:US
Practice Address - Phone:510-663-7313
Practice Address - Fax:510-663-5908
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8133Medicaid