Provider Demographics
NPI:1063479178
Name:GOSSEN, DIANE K (LSCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:GOSSEN
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 N WACO
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3939
Mailing Address - Country:US
Mailing Address - Phone:316-263-2351
Mailing Address - Fax:316-263-3685
Practice Address - Street 1:833 N WACO
Practice Address - Street 2:SUITE 200
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3939
Practice Address - Country:US
Practice Address - Phone:316-263-2351
Practice Address - Fax:316-263-3685
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS057675OtherBCBS
KS057675OtherBCBS
S25924Medicare UPIN