Provider Demographics
NPI:1821229188
Name:WILSON, DIANE GRIMARD (LCPC, BCN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:GRIMARD
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPC, BCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W WACKER DR STE 500
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1225
Mailing Address - Country:US
Mailing Address - Phone:312-925-5176
Mailing Address - Fax:
Practice Address - Street 1:333 W WACKER DR STE 500
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-1225
Practice Address - Country:US
Practice Address - Phone:312-925-5176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180001245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional