Basic Information
| Provider Information | |||||||||
| NPI: | 1508877176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGEL | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MA, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 540 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524424437 | ||||||||
| FaxNumber: | 9524423084 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524424437 | ||||||||
| FaxNumber: | 9524423084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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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 | 103TC0700X | LP1611 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 712753700 | 05 | MN | MEDICAID |