Provider Demographics
NPI:1154626810
Name:LETT, DIANA WILDER (LCSW, LISAC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:WILDER
Last Name:LETT
Suffix:
Gender:F
Credentials:LCSW, LISAC
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:LETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, LISAC
Mailing Address - Street 1:2561 E FORT LOWELL RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1540
Mailing Address - Country:US
Mailing Address - Phone:520-977-0870
Mailing Address - Fax:520-327-0229
Practice Address - Street 1:2561 E FORT LOWELL RD
Practice Address - Street 2:SUITE 2
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-1540
Practice Address - Country:US
Practice Address - Phone:520-977-0870
Practice Address - Fax:520-327-0229
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11858101YA0400X
AZLCSW-131811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)