Provider Demographics
NPI:1003992934
Name:STAIB, DIANE L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:L
Last Name:STAIB
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:35 SWALLOW ST # 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-3212
Mailing Address - Country:US
Mailing Address - Phone:617-288-0970
Mailing Address - Fax:617-474-0757
Practice Address - Street 1:UPHAM'S ELDER SERVICE PLAN
Practice Address - Street 2:1140 DORCHESTER AVE
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125
Practice Address - Country:US
Practice Address - Phone:617-288-0970
Practice Address - Fax:617-474-0757
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2123491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical