Provider Demographics
NPI:1831377944
Name:POULOS, DIANNA KATHERINE (MA,BCBA)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:KATHERINE
Last Name:POULOS
Suffix:
Gender:F
Credentials:MA,BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4363 WATERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:ISLAND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60042-8221
Mailing Address - Country:US
Mailing Address - Phone:847-331-5370
Mailing Address - Fax:
Practice Address - Street 1:4363 WATERS EDGE DR
Practice Address - Street 2:
Practice Address - City:ISLAND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60042-8221
Practice Address - Country:US
Practice Address - Phone:847-331-5370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-09-6494103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst