Provider Demographics
NPI:1730272691
Name:DIANA, PHILIP ANTHONY (LICSW)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:ANTHONY
Last Name:DIANA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-843-8079
Mailing Address - Fax:
Practice Address - Street 1:100 LEDGEWOOD PL
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370
Practice Address - Country:US
Practice Address - Phone:781-871-6550
Practice Address - Fax:781-871-5973
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA102264751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23725Medicare ID - Type Unspecified