Provider Demographics
NPI:1427115716
Name:GARRISON, DIANE C (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:C
Last Name:GARRISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27100 WAUBEESEE LAKE DR
Mailing Address - Street 2:C/O KRISTY LAUX
Mailing Address - City:WIND LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53185-2053
Mailing Address - Country:US
Mailing Address - Phone:262-547-9673
Mailing Address - Fax:262-549-5107
Practice Address - Street 1:325 FOREST GROVE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3793
Practice Address - Country:US
Practice Address - Phone:262-547-9673
Practice Address - Fax:262-549-5107
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2274-057103TA0400X, 103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39146400Medicaid