Provider Demographics
NPI:1386684546
Name:MESA-HORAITIS, DIANA ANDREA (MS LMFT)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:ANDREA
Last Name:MESA-HORAITIS
Suffix:
Gender:F
Credentials:MS LMFT
Other - Prefix:MISS
Other - First Name:DIANA
Other - Middle Name:ANDREA
Other - Last Name:MESA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS LMFT
Mailing Address - Street 1:2906 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3732
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:414-672-4265
Practice Address - Street 1:2906 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3732
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:414-672-4265
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI415124101YM0800X, 106H00000X
WI415-124104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39615400Medicaid