Provider Demographics
NPI:1902241763
Name:PASSERO, DIANE HALLILA (LCPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:HALLILA
Last Name:PASSERO
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 WAKEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-4651
Mailing Address - Country:US
Mailing Address - Phone:503-522-0398
Mailing Address - Fax:301-952-2954
Practice Address - Street 1:2000 MARBURY DR
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-2334
Practice Address - Country:US
Practice Address - Phone:301-952-5498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional