Provider Demographics
NPI:1598985301
Name:MERCER, DIANE LOUISE (CASAC-T)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:MERCER
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 KING ST
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-4412
Mailing Address - Country:US
Mailing Address - Phone:631-920-8250
Mailing Address - Fax:631-920-8251
Practice Address - Street 1:240 LONG ISLAND AVE # A
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-3123
Practice Address - Country:US
Practice Address - Phone:631-920-8250
Practice Address - Fax:631-920-8251
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18272101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)