Provider Demographics
NPI:1750842399
Name:SCRUGGS, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SCRUGGS
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 1:338 S DANTE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-2044
Mailing Address - Country:US
Mailing Address - Phone:708-539-6484
Mailing Address - Fax:
Practice Address - Street 1:338 S DANTE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-2044
Practice Address - Country:US
Practice Address - Phone:708-539-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0035771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical