Provider Demographics
NPI:1861700650
Name:TATSUYAMA, DIANE NORIKO (CCC-SLP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:NORIKO
Last Name:TATSUYAMA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ALTADENA DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2982
Mailing Address - Country:US
Mailing Address - Phone:719-252-9154
Mailing Address - Fax:
Practice Address - Street 1:48 ALTADENA DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2982
Practice Address - Country:US
Practice Address - Phone:719-252-9154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01109363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist