Basic Information
| Provider Information | |||||||||
| NPI: | 1699391490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAMOND-ROBERTSON | ||||||||
| FirstName: | MARGO | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1623 EDGEWATER DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530954398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166990832 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2004 HIGHLAND AVE STE M | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547014389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158355915 | ||||||||
| FaxNumber: | 7158358112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2020 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1699391490 | 05 | WI | MEDICAID |