Provider Demographics
NPI:1437759701
Name:CASTLEBERRY, DIANNA MICHELLE
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:MICHELLE
Last Name:CASTLEBERRY
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:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:BARRY
Mailing Address - State:IL
Mailing Address - Zip Code:62312-0024
Mailing Address - Country:US
Mailing Address - Phone:217-335-2961
Mailing Address - Fax:
Practice Address - Street 1:1166 MASON ST
Practice Address - Street 2:
Practice Address - City:BARRY
Practice Address - State:IL
Practice Address - Zip Code:62312-1137
Practice Address - Country:US
Practice Address - Phone:217-335-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85-364764Medicaid