Provider Demographics
NPI:1508213844
Name:DIANE JOHNSON PROSSER, PHD., LLC
Entity Type:Organization
Organization Name:DIANE JOHNSON PROSSER, PHD., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:PROSSER
Authorized Official - Suffix:
Authorized Official - Credentials:HSPP
Authorized Official - Phone:574-850-8486
Mailing Address - Street 1:227 N DIXIE WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-3385
Mailing Address - Country:US
Mailing Address - Phone:574-850-8486
Mailing Address - Fax:574-966-1580
Practice Address - Street 1:227 N DIXIE WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3385
Practice Address - Country:US
Practice Address - Phone:574-850-8486
Practice Address - Fax:574-966-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200122760AMedicaid
INS29118Medicare UPIN