Basic Information
Provider Information
NPI: 1003000605
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FREEMAN
FirstName: DIANE
MiddleName: ELIZABETH
NamePrefix: MRS.
NameSuffix:  
Credential: OTR
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: DEAVER
OtherFirstName: DIANE
OtherMiddleName: ELIZABETH
OtherNamePrefix: MISS
OtherNameSuffix:  
OtherCredential: OTR
OtherLastNameType: 1
Mailing Information
Address1: 11035 E RICHFIELD RD
Address2:  
City: DAVISON
State: MI
PostalCode: 484238517
CountryCode: US
TelephoneNumber: 8106542422
FaxNumber:  
Practice Location
Address1: 11035 E RICHFIELD RD
Address2:  
City: DAVISON
State: MI
PostalCode: 484238517
CountryCode: US
TelephoneNumber: 8106542422
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/28/2007
LastUpdateDate: 04/26/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X5201003946MIY Other Service ProvidersSpecialist 

No ID Information.


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