Provider Demographics
NPI:1114674512
Name:ACK-MITCHELL, DIANE S
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:ACK-MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 UXBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691-4016
Mailing Address - Country:US
Mailing Address - Phone:609-413-6339
Mailing Address - Fax:
Practice Address - Street 1:30 PECK RD STE 2105
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6123
Practice Address - Country:US
Practice Address - Phone:860-361-6204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5358101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health