Provider Demographics
NPI:1255632337
Name:DIENER, MARC JOSHUA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:JOSHUA
Last Name:DIENER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 ROCKAWAY AVE
Mailing Address - Street 2:SUITE 206A
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1665
Mailing Address - Country:US
Mailing Address - Phone:646-246-1662
Mailing Address - Fax:646-871-0203
Practice Address - Street 1:1800 ROCKAWAY AVE
Practice Address - Street 2:SUITE 206A
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1665
Practice Address - Country:US
Practice Address - Phone:646-246-1662
Practice Address - Fax:646-871-0203
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68017465103T00000X
VA0810003955103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical