Provider Demographics
NPI:1487709275
Name:QUENSEN-DIEZ, ERICA ANN (MA, LCPC, ADTR)
Entity type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:ANN
Last Name:QUENSEN-DIEZ
Suffix:
Gender:F
Credentials:MA, LCPC, ADTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 COVINGTON CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-5504
Mailing Address - Country:US
Mailing Address - Phone:630-401-0264
Mailing Address - Fax:815-254-3419
Practice Address - Street 1:24402 W LOCKPORT RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-4206
Practice Address - Country:US
Practice Address - Phone:630-401-0264
Practice Address - Fax:815-254-3419
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009932406OtherBCBS PROVIDER NUMBER