Basic Information
| Provider Information | |||||||||
| NPI: | 1851843411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN BRUGGEN | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | JOYCE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, ATR-BC, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZAMRAZIL | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | JOYCE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 494 DOVER POND DR | ||||||||
| Address2: | |||||||||
| City: | BLACKLICK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430048052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142040974 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 547 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432112603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142244506 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2016 | ||||||||
| LastUpdateDate: | 10/31/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C 0600219 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.