Provider Demographics
NPI:1386189504
Name:STILLWAGON, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:STILLWAGON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 COMMERCE DR NW
Mailing Address - Street 2:APT 3403
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-3176
Mailing Address - Country:US
Mailing Address - Phone:717-991-9450
Mailing Address - Fax:
Practice Address - Street 1:7100 PEACHTREE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-1689
Practice Address - Country:US
Practice Address - Phone:404-245-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009424235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist