Provider Demographics
NPI:1265501688
Name:GUTMAN, DIANE J (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:J
Last Name:GUTMAN
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 1:200 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4235
Mailing Address - Country:US
Mailing Address - Phone:516-731-4901
Mailing Address - Fax:516-731-9308
Practice Address - Street 1:200 OLD COUNTRY RD
Practice Address - Street 2:SUITE 520
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4235
Practice Address - Country:US
Practice Address - Phone:516-731-4901
Practice Address - Fax:516-731-9308
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040512-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1104980OtherOXFORD HEALTH PLANS
NYN46371Medicare ID - Type Unspecified