Provider Demographics
NPI:1356323505
Name:RADISEWITZ ROMMES, DIANE K (PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:RADISEWITZ ROMMES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4116
Mailing Address - Country:US
Mailing Address - Phone:608-392-9555
Mailing Address - Fax:608-392-9432
Practice Address - Street 1:212 11TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4116
Practice Address - Country:US
Practice Address - Phone:608-392-9555
Practice Address - Fax:608-392-9432
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1417103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P95023Medicare UPIN