Provider Demographics
NPI:1285247213
Name:DEVRIES, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5813 1110TH ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:WI
Mailing Address - Zip Code:54021-7727
Mailing Address - Country:US
Mailing Address - Phone:715-441-0072
Mailing Address - Fax:
Practice Address - Street 1:N5813 1110TH ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:WI
Practice Address - Zip Code:54021-7727
Practice Address - Country:US
Practice Address - Phone:715-441-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10468101YP2500X
WI10510101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid