Provider Demographics
NPI:1699391490
Name:DIAMOND-ROBERTSON, MARGO ELAINE
Entity Type:Individual
Prefix:
First Name:MARGO
Middle Name:ELAINE
Last Name:DIAMOND-ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4398
Mailing Address - Country:US
Mailing Address - Phone:716-699-0832
Mailing Address - Fax:
Practice Address - Street 1:2004 HIGHLAND AVE STE M
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4389
Practice Address - Country:US
Practice Address - Phone:715-835-5915
Practice Address - Fax:715-835-8112
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1699391490Medicaid