Provider Demographics
NPI:1780161661
Name:GRACE, DIANA
Entity type:Individual
Prefix:MISS
First Name:DIANA
Middle Name:
Last Name:GRACE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 KINGERY HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-2250
Mailing Address - Country:US
Mailing Address - Phone:630-446-2601
Mailing Address - Fax:
Practice Address - Street 1:6300 KINGERY HWY STE 102
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-2250
Practice Address - Country:US
Practice Address - Phone:630-446-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-24-77143103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty