Provider Demographics
NPI:1649367665
Name:CHACON, DIANA (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:CHACON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 BLOOMFIELD ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4747
Mailing Address - Country:US
Mailing Address - Phone:201-714-4600
Mailing Address - Fax:201-255-0888
Practice Address - Street 1:223 BLOOMFIELD ST
Practice Address - Street 2:SUITE 112
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4747
Practice Address - Country:US
Practice Address - Phone:201-714-4600
Practice Address - Fax:201-255-0888
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100382000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ041464Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER