Healthcare Provider Details

I. General information

NPI: 1427115716
Provider Name (Legal Business Name): DIANE C GARRISON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 FOREST GROVE DR SUITE 201
PEWAUKEE WI
53072-3793
US

IV. Provider business mailing address

27100 WAUBEESEE LAKE DR C/O KRISTY LAUX
WIND LAKE WI
53185-2053
US

V. Phone/Fax

Practice location:
  • Phone: 262-547-9673
  • Fax: 262-549-5107
Mailing address:
  • Phone: 262-547-9673
  • Fax: 262-549-5107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number2274-057
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2274-057
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2274-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: