Provider Demographics
NPI:1891902979
Name:ROTNEM, DIANE LOUISE (PHD, LICSW)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LOUISE
Last Name:ROTNEM
Suffix:
Gender:F
Credentials:PHD, LICSW
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:LOUISE
Other - Last Name:ROTNEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:42 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-4810
Mailing Address - Country:US
Mailing Address - Phone:203-453-1572
Mailing Address - Fax:
Practice Address - Street 1:42 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-4810
Practice Address - Country:US
Practice Address - Phone:203-453-1572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNAP08-9921041C0700X
MN195671041C0700X
CT0005351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT14000535CT 01OtherANTHEM PROVIDER ID