Provider Demographics
NPI:1235384892
Name:GEFROH, DIANA RAE (MSED, LPCC)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:RAE
Last Name:GEFROH
Suffix:
Gender:F
Credentials:MSED, LPCC
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1915 W. KAVANEY DR SUITE 4
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-255-3325
Mailing Address - Fax:701-250-6469
Practice Address - Street 1:1915 W. KAVANEY DR SUITE 4
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-255-3325
Practice Address - Fax:701-250-6469
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND611-9-1-08A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1473341Medicaid