Provider Demographics
NPI:1952452534
Name:PROSSER, DIANE JOHNSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:JOHNSON
Last Name:PROSSER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:JOHNSON
Other - Last Name:PROSSER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:227 N DIXIE WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-3366
Mailing Address - Country:US
Mailing Address - Phone:574-850-8486
Mailing Address - Fax:574-966-1585
Practice Address - Street 1:227 N DIXIE WAY STE 110
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3366
Practice Address - Country:US
Practice Address - Phone:574-850-8486
Practice Address - Fax:574-966-1585
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200122760AMedicaid
INS29118Medicare UPIN
IN200122760AMedicaid