Provider Demographics
NPI:1720143761
Name:KING, DIANE DAYLE (CCC SLP CERTIFICATE)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:DAYLE
Last Name:KING
Suffix:
Gender:F
Credentials:CCC SLP CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 COUNTRY CLUB LANE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840
Mailing Address - Country:US
Mailing Address - Phone:406-363-5358
Mailing Address - Fax:
Practice Address - Street 1:579 COUNTRY CLUB LANE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840
Practice Address - Country:US
Practice Address - Phone:406-363-5358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT54235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT660730OtherBL CROSS BL SHIELD
MT0530230Medicaid