Provider Demographics
NPI:1902191638
Name:QUEALY-BERGE, DIANA PAULINE (PHD WY LPC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:PAULINE
Last Name:QUEALY-BERGE
Suffix:
Gender:F
Credentials:PHD WY LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82602-0235
Mailing Address - Country:US
Mailing Address - Phone:307-277-6462
Mailing Address - Fax:
Practice Address - Street 1:3920 SWINGLE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604
Practice Address - Country:US
Practice Address - Phone:307-315-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWY LPC 386101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor