Provider Demographics
NPI:1609324359
Name:KWACZ, DIANA (PSY)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KWACZ
Suffix:
Gender:F
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-3425
Mailing Address - Country:US
Mailing Address - Phone:302-995-8000
Mailing Address - Fax:302-995-6235
Practice Address - Street 1:1417 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-3425
Practice Address - Country:US
Practice Address - Phone:302-995-8000
Practice Address - Fax:302-995-6235
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE85502103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool