Basic Information
| Provider Information | |||||||||
| NPI: | 1457311532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | W8362 ROYAL OAKS DR | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549825313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207870142 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 108 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | FRIENDSHIP | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539349443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083394511 | ||||||||
| FaxNumber: | 6083394593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3450-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.