Provider Demographics
NPI:1184141632
Name:WILSON, DIANE M (MED)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:BARRIEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 SCHOOL ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2781
Mailing Address - Country:US
Mailing Address - Phone:978-630-4918
Mailing Address - Fax:978-630-3049
Practice Address - Street 1:205 SCHOOL ST. #202
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-630-4918
Practice Address - Fax:978-630-3049
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health