Provider Demographics
NPI:1982610986
Name:BERRY, DIANE M (MSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:BERRY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4847
Mailing Address - Country:US
Mailing Address - Phone:920-683-3911
Mailing Address - Fax:920-683-3911
Practice Address - Street 1:2215 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4847
Practice Address - Country:US
Practice Address - Phone:920-683-3911
Practice Address - Fax:920-683-3911
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65311231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39759100Medicaid
S41174Medicare UPIN
WI000144375Medicare PIN