Provider Demographics
NPI:1669599072
Name:WILDMAN, DIANE MARIE (MALPC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:MALPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18070 CINNAMON TRL
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255-9560
Mailing Address - Country:US
Mailing Address - Phone:440-543-2455
Mailing Address - Fax:
Practice Address - Street 1:611 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-1037
Practice Address - Country:US
Practice Address - Phone:330-744-2991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC-0004924101YM0800X, 101YS0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000126040OtherANTHEM BCBS
OH2164381OtherCIGNA BEHAVIORAL