Provider Demographics
NPI:1669581724
Name:GRANDE, DIANNE L (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:L
Last Name:GRANDE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DIANNE
Other - Middle Name:L
Other - Last Name:LEE-RIORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:516 WEST LANE
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1037
Mailing Address - Country:US
Mailing Address - Phone:630-208-1975
Mailing Address - Fax:630-879-6806
Practice Address - Street 1:335 N RIVER ST
Practice Address - Street 2:SUITE 210
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2386
Practice Address - Country:US
Practice Address - Phone:630-406-5493
Practice Address - Fax:630-879-6806
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004183103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2619OtherMEDICARE PTAN