Provider Demographics
NPI:1770252140
Name:RUDISAILE, DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:RUDISAILE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MICHELE
Other - Last Name:SLOANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:817-569-4300
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-335-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX283501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical