Provider Demographics
NPI:1457311532
Name:ANDERSON, DIANE KAY (LPC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:KAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8362 ROYAL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-5313
Mailing Address - Country:US
Mailing Address - Phone:920-787-0142
Mailing Address - Fax:
Practice Address - Street 1:108 E NORTH ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9443
Practice Address - Country:US
Practice Address - Phone:608-339-4511
Practice Address - Fax:608-339-4593
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3450-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional