Basic Information
| Provider Information | |||||||||
| NPI: | 1245394089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERP | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4745 DREW ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973052302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033909401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3180 CENTER ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035855351 | ||||||||
| FaxNumber: | 5035854908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.