Provider Demographics
NPI:1881094050
Name:THOMPSON, DIANE MARYIE (SUDCC II)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARYIE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:SUDCC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 E BARDSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-5400
Mailing Address - Country:US
Mailing Address - Phone:559-688-7531
Mailing Address - Fax:559-688-3509
Practice Address - Street 1:559 E BARDSLEY AVE
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-5400
Practice Address - Country:US
Practice Address - Phone:559-688-7531
Practice Address - Fax:559-688-3509
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL15046065101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5478OtherMEDICAL
CA1679797575OtherMEDI-CAL