Basic Information
| Provider Information | |||||||||
| NPI: | 1437265063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMIESON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 PINE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015501823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087659167 | ||||||||
| FaxNumber: | 5087642462 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 PINE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015501823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087659167 | ||||||||
| FaxNumber: | 5087642462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 10/07/2008 | ||||||||
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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 | 101YA0400X | 0358 | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2222001910 | 01 | MA | BCBS | OTHER | 1200704 | 05 | MA | MEDICAID |