Provider Demographics
NPI:1235516758
Name:RECOB, DIANE (CAPSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:RECOB
Suffix:
Gender:F
Credentials:CAPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5574 LONGFORD TER
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6900
Mailing Address - Country:US
Mailing Address - Phone:608-345-7018
Mailing Address - Fax:
Practice Address - Street 1:5574 LONGFORD TER
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-6900
Practice Address - Country:US
Practice Address - Phone:608-345-7018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129349121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker