Provider Demographics
NPI:1386658649
Name:BOLMES, DIANA LYNN (LCSW, CSAC)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:LYNN
Last Name:BOLMES
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2504
Mailing Address - Country:US
Mailing Address - Phone:414-454-6502
Mailing Address - Fax:414-454-6751
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2504
Practice Address - Country:US
Practice Address - Phone:414-454-6502
Practice Address - Fax:414-454-6751
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11208101YA0400X
WI7030-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40919900Medicaid
WI40919900Medicaid