Provider Demographics
NPI:1235803784
Name:ENTLER, DIANDRA (MS, LCSW, CCLS)
Entity Type:Individual
Prefix:
First Name:DIANDRA
Middle Name:
Last Name:ENTLER
Suffix:
Gender:F
Credentials:MS, LCSW, CCLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 W DIVERSEY PKWY UNIT G2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1201
Mailing Address - Country:US
Mailing Address - Phone:312-725-4879
Mailing Address - Fax:
Practice Address - Street 1:1209 W DIVERSEY PKWY UNIT G2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1201
Practice Address - Country:US
Practice Address - Phone:312-725-4879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0231661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.023166OtherLCSW LICENSE