Provider Demographics
NPI:1598006637
Name:FENSKE, DIANE LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:FENSKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 S STATE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6184
Mailing Address - Country:US
Mailing Address - Phone:734-769-0209
Mailing Address - Fax:734-769-0224
Practice Address - Street 1:2245 S STATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6184
Practice Address - Country:US
Practice Address - Phone:734-769-0209
Practice Address - Fax:734-769-0224
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801020541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health