Provider Demographics
NPI:1619190006
Name:ANDERSON, DIANA KAY (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:KAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-1851
Mailing Address - Country:US
Mailing Address - Phone:309-883-1646
Mailing Address - Fax:
Practice Address - Street 1:3020 W WILLOW KNOLLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8127
Practice Address - Country:US
Practice Address - Phone:309-681-5652
Practice Address - Fax:309-681-5658
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.009965101YM0800X, 104100000X
IL1490128441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150.009965OtherDPR LICENSE
IL370984175OtherBWAY, INC FEIN
IL370984175OtherBWAY, INC FEIN