1265658157 NPI number — DR. DIANE MARCY MEADOW MSW PHD

Table of content: (NPI 1245487180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265658157 NPI number — DR. DIANE MARCY MEADOW MSW PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEADOW
Provider First Name:
DIANE
Provider Middle Name:
MARCY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MSW PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265658157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23891 BOTHNIA BAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANA POINT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92629-4403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-707-5191
Provider Business Mailing Address Fax Number:
949-496-6027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15615 ALTON PKWY
Provider Second Line Business Practice Location Address:
STE 220
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-707-5191
Provider Business Practice Location Address Fax Number:
949-496-6027
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS5702 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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