Provider Demographics
NPI:1902194616
Name:CONOVER, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:CONOVER
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 1:607 LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5727
Mailing Address - Country:US
Mailing Address - Phone:219-548-8727
Mailing Address - Fax:219-465-7211
Practice Address - Street 1:607 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5727
Practice Address - Country:US
Practice Address - Phone:219-548-8727
Practice Address - Fax:219-465-7211
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200275200AMedicaid
IN200275200AMedicaid