Provider Demographics
NPI:1689183592
Name:WALLENDJACK, DIANE LOUISE (EDD, NCSP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:WALLENDJACK
Suffix:
Gender:F
Credentials:EDD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1974
Mailing Address - Country:US
Mailing Address - Phone:708-447-3896
Mailing Address - Fax:
Practice Address - Street 1:65 WOODSIDE RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1974
Practice Address - Country:US
Practice Address - Phone:708-447-3896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL899294103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool