Provider Demographics
NPI:1750171393
Name:BENNINGTON, DIANA MARIE
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:BENNINGTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8665
Mailing Address - Country:US
Mailing Address - Phone:458-225-9358
Mailing Address - Fax:
Practice Address - Street 1:248 MACE RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-1280
Practice Address - Country:US
Practice Address - Phone:541-727-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25-QMHA-R-6846171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator