| Diane Johnson Prosser, Phd., Llc | |
|
227 N Dixie Way Suite 110 South Bend IN 46637-3385 | |
| (574) 850-8486 | |
| (574) 966-1580 |
| Full Name | Diane Johnson Prosser, Phd., Llc |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 227 N Dixie Way, South Bend, Indiana |
| Authorized Official Name and Position | Diane Johnson Prosser (SOLE PROPRIETOR) |
| Authorized Official Contact | 5748508486 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Diane Johnson Prosser, Phd., Llc 227 N Dixie Way Suite 110 South Bend IN 46637-3385 Ph: (574) 850-8486 | Diane Johnson Prosser, Phd., Llc 227 N Dixie Way Suite 110 South Bend IN 46637-3385 Ph: (574) 850-8486 |
| NPI Number | 1508213844 |
|---|---|
| Provider Enumeration Date | 05/17/2016 |
| Last Update Date | 05/17/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1508213844 | NPI | - | NPPES |
| 200122760A | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 20040993 (Indiana) | Primary |
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