Healthcare Provider Details

I. General information

NPI: 1598985301
Provider Name (Legal Business Name): DIANE LOUISE MERCER CASAC-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 LONG ISLAND AVE # A
WYANDANCH NY
11798-3123
US

IV. Provider business mailing address

34 KING ST
WYANDANCH NY
11798-4412
US

V. Phone/Fax

Practice location:
  • Phone: 631-920-8250
  • Fax: 631-920-8251
Mailing address:
  • Phone: 631-920-8250
  • Fax: 631-920-8251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18272
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: