Provider Demographics
NPI:1831264274
Name:GARD, DIANE MARILEE (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARILEE
Last Name:GARD
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:PO BOX 2107
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75147-5017
Mailing Address - Country:US
Mailing Address - Phone:903-368-2299
Mailing Address - Fax:903-489-0111
Practice Address - Street 1:122 S GUN BARREL LN
Practice Address - Street 2:SUITE 6
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-9403
Practice Address - Country:US
Practice Address - Phone:903-887-0697
Practice Address - Fax:903-887-0698
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2264103T00000X
TX33829103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX614301OtherMEDICARE B