Provider Demographics
NPI:1134291552
Name:MROSS, DIANE JOY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:JOY
Last Name:MROSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:J
Other - Last Name:GOODLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1320 W CLAIREMONT AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4566
Mailing Address - Country:US
Mailing Address - Phone:715-834-2046
Mailing Address - Fax:715-834-7563
Practice Address - Street 1:2350 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6272
Practice Address - Country:US
Practice Address - Phone:715-838-9856
Practice Address - Fax:715-838-7289
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI911-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39556000Medicaid
WI39556000Medicaid