Provider Demographics
NPI:1114994100
Name:MIDGLEY, DIANA L (LMSW)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:L
Last Name:MIDGLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1048
Mailing Address - Country:US
Mailing Address - Phone:517-768-1700
Mailing Address - Fax:517-768-1739
Practice Address - Street 1:569 WILDWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1048
Practice Address - Country:US
Practice Address - Phone:517-768-1700
Practice Address - Fax:517-768-1739
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010706621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI457611OtherVALUEOPTIONS
MI38335OtherPPOM
MI7066333OtherAETNA
MI8008974720OtherBLUE CROSS/BLUE SHIELD
MI87726OtherUNITED HEALTH CARE
MIIP 528494OtherMAGELLAN
MI80-0-89-7472-0OtherBLUE CARE NETWORK
MI87726OtherUNITED HEALTH CARE