Provider Demographics
NPI:1801576079
Name:RICHARDS-PENLAND, DIANE J (LADC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:J
Last Name:RICHARDS-PENLAND
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 KETTLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2641
Mailing Address - Country:US
Mailing Address - Phone:203-560-6301
Mailing Address - Fax:
Practice Address - Street 1:60 &70 COTTAGE ST.
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06329
Practice Address - Country:US
Practice Address - Phone:860-774-0215
Practice Address - Fax:860-774-2256
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001484101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008024427Medicaid
CT008023170Medicaid
CT008042339Medicaid
CT008109605Medicaid
CT008039745Medicaid