Provider Demographics
NPI:1023168531
Name:TENNIES, DIANE ALICIA (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ALICIA
Last Name:TENNIES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 FRANKLIN ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4936
Mailing Address - Country:US
Mailing Address - Phone:207-942-3635
Mailing Address - Fax:207-941-1933
Practice Address - Street 1:115 FRANKLIN ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4936
Practice Address - Country:US
Practice Address - Phone:207-942-3635
Practice Address - Fax:207-941-1933
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC 1572103TA0400X
MEPS955103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME043983OtherBLUE CROSS BLUE SHIELD
ME231220000Medicaid
MEMM7707Medicare ID - Type Unspecified
MEMM770703Medicare PIN