Basic Information
| Provider Information | |||||||||
| NPI: | 1497314264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 270 FARMINGTON AVE STE 328 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060321909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668876864 | ||||||||
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| Practice Location | |||||||||
| Address1: | 270 FARMINGTON AVE STE 328 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060321909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668876864 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2019 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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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 | 103TC0700X | 003371 | CT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.