Provider Demographics
NPI:1013064369
Name:CALCOTT, DIANA L (MA LP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:CALCOTT
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 WOODSIDE TRL NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2580
Mailing Address - Country:US
Mailing Address - Phone:616-453-1835
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:830 JORDAN LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-1270
Practice Address - Country:US
Practice Address - Phone:616-374-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005659101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor