Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | ||
N | 103T00000X | Psychologist | ||
N | 102L00000X | Psychologist | 1831-057 | WI |
N | 103T00000X | Psychologist | 1831-057 | WI |
N | 103TF0000X | Family Psychologist | 1838-057 | WI |
N | 103TH0100X | Health Service | 1831-057 | WI |
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 442 | WI |
NPI | 1366467235 |
---|---|
Provider Name | Diane Matel |
First Address | Mequon, WI 53092-3477 |
Second Address | Mequon, WI 53092-3477 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2006 |
Last Update Date | 13/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39401900 | (05) | WI |