Provider Demographics
NPI:1265449912
Name:BURGRAVE, DIANA (LCSW R)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:BURGRAVE
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BEACH 117TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694
Mailing Address - Country:US
Mailing Address - Phone:718-634-3594
Mailing Address - Fax:
Practice Address - Street 1:316 BEACH 65TH ST
Practice Address - Street 2:DAYTOP VILLAGE INC
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11692
Practice Address - Country:US
Practice Address - Phone:718-474-3800
Practice Address - Fax:718-318-6372
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0255591104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker