Basic Information
| Provider Information | |||||||||
| NPI: | 1063639524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S IDAHO ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LA HABRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906316047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626900400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2707 E 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166910249 | ||||||||
| FaxNumber: | 3166919875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 961 | KS | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PY01796 | MO | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | SW001771 | MO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363A00000X | PA54144 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 15-01466 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100212200B | 05 | KS | MEDICAID |