Provider Demographics
NPI:1326266941
Name:PETERSON, DIANNE L (BSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COUNTY ROAD, OA , N 2367
Mailing Address - Street 2:
Mailing Address - City:LACROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601
Mailing Address - Country:US
Mailing Address - Phone:608-787-0031
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST STE 100
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2378
Practice Address - Country:US
Practice Address - Phone:608-785-5913
Practice Address - Fax:608-785-6315
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2674-120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator