Provider Demographics
NPI:1093335150
Name:ALTSTADT, DIANA (LMT, LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ALTSTADT
Suffix:
Gender:F
Credentials:LMT, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 N 100TH ST UNIT 310
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10625 W NORTH AVE STE 102
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-678-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-19
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7558-1231041C0700X
WI1221-46225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical