Provider Demographics
NPI:1548481930
Name:RAGER, DIANE RENE' (BS)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:RENE'
Last Name:RAGER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 W RAVINA AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3136
Mailing Address - Country:US
Mailing Address - Phone:217-972-1553
Mailing Address - Fax:217-872-1491
Practice Address - Street 1:1335 W RAVINA AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3136
Practice Address - Country:US
Practice Address - Phone:217-972-1553
Practice Address - Fax:217-872-1491
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL055Medicaid