Provider Demographics
NPI:1053628438
Name:DESMARAIS, DIANE C (LPC, LADC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:DESMARAIS
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-575-0466
Mailing Address - Fax:203-575-1817
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2310
Practice Address - Country:US
Practice Address - Phone:203-575-0466
Practice Address - Fax:203-575-1817
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000822101YA0400X
CT001894101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)