Provider Demographics
NPI:1447295043
Name:BRANDMILLER, DIANE M (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:BRANDMILLER
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:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2592 N. GREGG AVENUE, SUITE 34
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-225-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR05-14P103TC0700X
MO2013010695103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162149719OtherDOMHA MCD
AR5A091OtherDOMHA BCBS
AR5Y827OtherDOMHA MCR
ARP00363OtherDOMHA MCR RR