Provider Demographics
NPI:1982634317
Name:WOMACK-WALTERS, DIANA E (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:E
Last Name:WOMACK-WALTERS
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:P.O. BOX 100
Mailing Address - Street 2:GOVA HEALTH, LTD
Mailing Address - City:ENERGY
Mailing Address - State:IL
Mailing Address - Zip Code:62933
Mailing Address - Country:US
Mailing Address - Phone:618-988-9843
Mailing Address - Fax:618-942-8640
Practice Address - Street 1:202 S. PERSHING ST.
Practice Address - Street 2:GOYA HEALTH, LTD
Practice Address - City:ENERGY
Practice Address - State:IL
Practice Address - Zip Code:62933
Practice Address - Country:US
Practice Address - Phone:618-988-9843
Practice Address - Fax:618-942-8640
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490055961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209110Medicare ID - Type Unspecified