Provider Demographics
NPI:1427381045
Name:WILLIAMSON, DIANE M (LMT, CMCE)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:LMT, CMCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NORTH PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-387-9445
Mailing Address - Fax:
Practice Address - Street 1:15 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3563
Practice Address - Country:US
Practice Address - Phone:847-387-9445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.004157225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist