Provider Demographics
NPI:1891902979
Name:ROTNEM, DIANE LOUISE (PHD, LICSW)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LOUISE
Last Name:ROTNEM
Suffix:
Gender:F
Credentials:PHD, LICSW
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:LOUISE
Other - Last Name:ROTNEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1406 6TH AVENUE NORTH
Mailing Address - Street 2:ST. CLOUD HOSPITAL
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-229-5109
Practice Address - Street 1:1406 6TH AVENUE NORTH
Practice Address - Street 2:ST. CLOUD HOSPITAL
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-229-5109
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0005351041C0700X
MNAP08-9921041C0700X
MN195671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT14000535CT 01OtherANTHEM PROVIDER ID