Provider Demographics
NPI:1770109746
Name:MARCINIAK, DIANA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MARCINIAK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:CIUPAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:2011 S CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1828
Mailing Address - Country:US
Mailing Address - Phone:734-394-2890
Mailing Address - Fax:
Practice Address - Street 1:26715 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4717
Practice Address - Country:US
Practice Address - Phone:248-557-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000794235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist