Basic Information
| Provider Information | |||||||||
| NPI: | 1215477906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONNERSTATER | ||||||||
| FirstName: | DIANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 E WEST MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | WALLED LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483903571 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 E WEST MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | WALLED LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483903571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483132900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2017 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801046555 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.