Provider Demographics
NPI:1386998938
Name:WALL- DUDLEY, DIANA L (LCSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:WALL- DUDLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 VANDALIA ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4848
Mailing Address - Country:US
Mailing Address - Phone:618-345-9536
Mailing Address - Fax:618-345-9587
Practice Address - Street 1:2014 VANDALIA ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4848
Practice Address - Country:US
Practice Address - Phone:618-345-9536
Practice Address - Fax:618-345-9587
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0099471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical