Provider Demographics
NPI:1144221243
Name:FELDMAN, DIANE C WHITLEY (PHDL)
Entity type:Individual
Prefix:
First Name:DIANE C
Middle Name:WHITLEY
Last Name:FELDMAN
Suffix:
Gender:F
Credentials:PHDL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4083 SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1245
Mailing Address - Country:US
Mailing Address - Phone:952-926-2777
Mailing Address - Fax:952-926-2777
Practice Address - Street 1:4083 SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1245
Practice Address - Country:US
Practice Address - Phone:952-926-2777
Practice Address - Fax:952-926-2777
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0806103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP0806OtherMN BOARD OF PSYCH LICENSE
MN04420FEOtherBCBS PROVIDER NUMBER
MN680001598Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST