Provider Demographics
NPI:1447384599
Name:WIEGAND, DIANE L (LMSW ACSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:L
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:LMSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1576 PECK STREET
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442
Mailing Address - Country:US
Mailing Address - Phone:231-727-2901
Mailing Address - Fax:231-725-7241
Practice Address - Street 1:1576 PECK STREET
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442
Practice Address - Country:US
Practice Address - Phone:231-727-2901
Practice Address - Fax:231-725-7241
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010806751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
830360531OtherBCBS
830360531OtherBCBS