Provider Demographics
NPI:1144817313
Name:ATSIDAKOS, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ATSIDAKOS
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 1:3527 KADY AVE NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-3090
Mailing Address - Country:US
Mailing Address - Phone:612-999-0969
Mailing Address - Fax:
Practice Address - Street 1:7615 GOLDEN TRIANGLE DR STE A
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3733
Practice Address - Country:US
Practice Address - Phone:612-400-6119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician