Provider Demographics
NPI:1174721328
Name:DOVENBERG, DIANE CAROL (MSW)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:CAROL
Last Name:DOVENBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 ORANGE AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4139
Mailing Address - Country:US
Mailing Address - Phone:651-487-2450
Mailing Address - Fax:651-487-2739
Practice Address - Street 1:646 ORANGE AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-4139
Practice Address - Country:US
Practice Address - Phone:651-487-2450
Practice Address - Fax:651-487-2739
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical