Provider Demographics
NPI:1083995773
Name:BALL, DIANA M (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:BALL
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 1:10515 HICKORY TREE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1023
Mailing Address - Country:US
Mailing Address - Phone:859-475-3247
Mailing Address - Fax:
Practice Address - Street 1:9417 SAINT JOE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-9259
Practice Address - Country:US
Practice Address - Phone:859-475-3247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6059101YM0800X
1041C0700X
KY2539741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300063943Medicaid
OH0000468Medicaid
KY1790731081Medicaid