Provider Demographics
NPI:1295280337
Name:ANDERSON, DIANA LEE
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LEE
Other - Last Name:MILLIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAC-IT
Mailing Address - Street 1:6815 W CAPITOL DR STE 112
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2056
Mailing Address - Country:US
Mailing Address - Phone:414-763-7671
Mailing Address - Fax:414-488-2969
Practice Address - Street 1:6815 W CAPITOL DR STE 112
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2056
Practice Address - Country:US
Practice Address - Phone:414-763-7671
Practice Address - Fax:414-488-2969
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)