Provider Demographics
NPI:1952813552
Name:POWELL, DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1608
Mailing Address - Country:US
Mailing Address - Phone:847-256-2216
Mailing Address - Fax:
Practice Address - Street 1:550 W FRONTAGE RD STE 2810
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1239
Practice Address - Country:US
Practice Address - Phone:847-461-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0054461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical