Basic Information
| Provider Information | |||||||||
| NPI: | 1538312020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 27TH ST | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143012525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162970798 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 27TH ST | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143012525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162970798 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 10/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 004660-1 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 004660-1 | 01 | NY | NYS LICENSE | OTHER |