Provider Demographics
NPI:1497815617
Name:MITTELHAUSER, DIANE F (PSYD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:F
Last Name:MITTELHAUSER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 N RIVER ST STE 210
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2386
Mailing Address - Country:US
Mailing Address - Phone:630-879-8164
Mailing Address - Fax:630-879-6806
Practice Address - Street 1:335 N RIVER ST STE 210
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2386
Practice Address - Country:US
Practice Address - Phone:630-879-8164
Practice Address - Fax:630-879-6806
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004901103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL702010Medicare ID - Type Unspecified
ILL85253Medicare ID - Type Unspecified