Provider Demographics
NPI:1033293527
Name:BRATHWAITE, DIANA R (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:R
Last Name:BRATHWAITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 MACDOUGAL ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-2625
Mailing Address - Country:US
Mailing Address - Phone:718-953-8737
Mailing Address - Fax:
Practice Address - Street 1:1600 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4008
Practice Address - Country:US
Practice Address - Phone:718-327-1600
Practice Address - Fax:718-868-4792
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0530601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0072TJMedicare ID - Type Unspecified