Provider Demographics
NPI:1013276880
Name:ELLEN DIAMOND
Entity Type:Organization
Organization Name:ELLEN DIAMOND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMM, CPC,CEMP
Authorized Official - Prefix:
Authorized Official - First Name:LANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSHKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-904-7500
Mailing Address - Street 1:1866 SHERIDAN RD STE 207
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2545
Mailing Address - Country:US
Mailing Address - Phone:847-433-3815
Mailing Address - Fax:847-433-3203
Practice Address - Street 1:1866 SHERIDAN RD STE 207
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2545
Practice Address - Country:US
Practice Address - Phone:847-433-3815
Practice Address - Fax:847-433-3203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004187103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty