Provider Demographics
NPI:1679683981
Name:CORMICLE, DIANE E WILSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:E WILSON
Last Name:CORMICLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 AMALFI CT
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-5816
Mailing Address - Country:US
Mailing Address - Phone:703-507-1238
Mailing Address - Fax:540-751-9543
Practice Address - Street 1:118 AMALFI CT
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-5816
Practice Address - Country:US
Practice Address - Phone:703-507-1238
Practice Address - Fax:540-751-9543
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001915103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA350778OtherANTHEM BCBS PROVIDER