Provider Demographics
NPI:1083780779
Name:PISANO, DIANE (LCSW C)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:PISANO
Suffix:
Gender:F
Credentials:LCSW C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 IVY HILL LANE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-805-5124
Mailing Address - Fax:301-805-1351
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:SUITE 107
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-805-5124
Practice Address - Fax:301-805-1351
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDO6414104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD146561900Medicaid
MDR24347Medicare UPIN
MD646355Medicare PIN