Basic Information
Provider Information
NPI: 1003800889
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SPRING
FirstName: DIANA
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential: MALLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: CHILDRESS
OtherFirstName: DIANA
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: PO BOX 428
Address2:  
City: OWOSSO
State: MI
PostalCode: 488670428
CountryCode: US
TelephoneNumber: 9897236791
FaxNumber: 9897255061
Practice Location
Address1: 1555 INDUSTRIAL DR
Address2:  
City: OWOSSO
State: MI
PostalCode: 488679775
CountryCode: US
TelephoneNumber: 9897236791
FaxNumber: 9897255061
Other Information
ProviderEnumerationDate: 09/07/2005
LastUpdateDate: 01/30/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103T00000X6301009357MIY Behavioral Health & Social Service ProvidersPsychologist 

ID Information
IDTypeStateIssuerDescription
622417601 DBHOTHER
099578101MIHEALTHPLUSOTHER


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