Provider Demographics
NPI:1386367795
Name:HIETPAS, DIANE MARIE (MA, SAC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:HIETPAS
Suffix:
Gender:F
Credentials:MA, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135-0970
Mailing Address - Country:US
Mailing Address - Phone:715-799-5400
Mailing Address - Fax:715-799-1326
Practice Address - Street 1:W3275 WOLF RIVER DR
Practice Address - Street 2:
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135-9202
Practice Address - Country:US
Practice Address - Phone:715-799-5400
Practice Address - Fax:715-799-1326
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16529-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)