Provider Demographics
NPI:1033217955
Name:BAUMBACH, DIANE KAY (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:KAY
Last Name:BAUMBACH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7055 148TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-9054
Mailing Address - Country:US
Mailing Address - Phone:218-791-5669
Mailing Address - Fax:
Practice Address - Street 1:2755 10TH AVE N
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203
Practice Address - Country:US
Practice Address - Phone:701-738-0888
Practice Address - Fax:701-757-1431
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND29711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1456202Medicaid