Provider Demographics
NPI:1699391490
Name:DIAMOND-ROBERTSON, MARGO ELAINE
Entity type:Individual
Prefix:
First Name:MARGO
Middle Name:ELAINE
Last Name:DIAMOND-ROBERTSON
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 1:1905 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-4917
Mailing Address - Country:US
Mailing Address - Phone:715-898-1665
Mailing Address - Fax:
Practice Address - Street 1:1905 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4917
Practice Address - Country:US
Practice Address - Phone:715-898-1665
Practice Address - Fax:715-898-1240
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1699391490Medicaid