Provider Demographics
NPI:1053492520
Name:BAUER, DIANE ELIZABETH (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:BAUER
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 1:1213 SILVERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8684
Mailing Address - Country:US
Mailing Address - Phone:651-731-1196
Mailing Address - Fax:
Practice Address - Street 1:4505 WHITE BEAR PKWY
Practice Address - Street 2:SUITE 1800
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3678
Practice Address - Country:US
Practice Address - Phone:651-426-8191
Practice Address - Fax:651-426-6766
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2107104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-74660OtherUBH
MN4G022DAOtherBLUE CROSS/BLUE SHIELD