Provider Demographics
NPI:1437385259
Name:WILSON, DIANE B
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:B
Last Name:WILSON
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 1:45439 LIVE OAK DRIVE
Mailing Address - Street 2:FISCAL DEPARTMENT
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401
Mailing Address - Country:US
Mailing Address - Phone:225-567-3111
Mailing Address - Fax:225-567-2017
Practice Address - Street 1:45439 LIVE OAK DRIVE
Practice Address - Street 2:FISCAL DEPARTMENT
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401
Practice Address - Country:US
Practice Address - Phone:225-567-3111
Practice Address - Fax:225-567-2017
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1296104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical