Provider Demographics
NPI:1265095954
Name:DIASIO, KRISTIN CAROL (MS SPECIAL EDUCATION)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:CAROL
Last Name:DIASIO
Suffix:
Gender:F
Credentials:MS SPECIAL EDUCATION
Other - Prefix:MRS
Other - First Name:KRISTIN
Other - Middle Name:CAROL
Other - Last Name:CHARGUALAF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA SOCIOLOGY
Mailing Address - Street 1:711 MEDFORD CTR # 264
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6772
Mailing Address - Country:US
Mailing Address - Phone:541-816-4415
Mailing Address - Fax:
Practice Address - Street 1:25 ERICKSON AVE
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539-9758
Practice Address - Country:US
Practice Address - Phone:541-816-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1386091569Medicaid