Provider Demographics
NPI:1114036043
Name:STUART, DIANE MIRANDA (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MIRANDA
Last Name:STUART
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:MIRANDA
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1730 MINOR AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1498
Mailing Address - Country:US
Mailing Address - Phone:206-287-2720
Mailing Address - Fax:206-287-2626
Practice Address - Street 1:1730 MINOR AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1498
Practice Address - Country:US
Practice Address - Phone:206-287-2720
Practice Address - Fax:206-287-2626
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 60067480101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8891182OtherMEDICARE PROVIDER NUMBER