Provider Demographics
NPI:1649555905
Name:WILLENS, DIANE GROSS (MACCC-SLP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:GROSS
Last Name:WILLENS
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5640 WESTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1237
Mailing Address - Country:US
Mailing Address - Phone:248-865-3452
Mailing Address - Fax:248-208-7494
Practice Address - Street 1:25865 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1817
Practice Address - Country:US
Practice Address - Phone:313-623-5898
Practice Address - Fax:248-208-7494
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI00512863235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist