Provider Demographics
NPI:1972521946
Name:DIEM, GRETCHEN A (PHD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:A
Last Name:DIEM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RAYOVAC DRIVE
Mailing Address - Street 2:SUITE 311
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2476
Mailing Address - Country:US
Mailing Address - Phone:608-492-0053
Mailing Address - Fax:
Practice Address - Street 1:700 RAYOVAC DRIVE
Practice Address - Street 2:SUITE 311
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2476
Practice Address - Country:US
Practice Address - Phone:608-492-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19404103T00000X
WI2591-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2591-57OtherPSYCH
CAPSY19404OtherPSYCH