Provider Demographics
NPI:1437265063
Name:JAMIESON, DIANE (CADAC)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:JAMIESON
Suffix:
Gender:F
Credentials:CADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-1823
Mailing Address - Country:US
Mailing Address - Phone:508-765-9167
Mailing Address - Fax:508-764-2462
Practice Address - Street 1:29 PINE ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-1823
Practice Address - Country:US
Practice Address - Phone:508-765-9167
Practice Address - Fax:508-764-2462
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0358101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2222001910OtherBCBS
MA1200704Medicaid
220019Medicare PIN