Provider Demographics
NPI:1275991853
Name:STEPHENS-SMITH, DIANE (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:STEPHENS-SMITH
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:WONDERFULLY MADE
Other - Middle Name:
Other - Last Name:SERVICES, LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9364
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23670-0364
Mailing Address - Country:US
Mailing Address - Phone:757-232-2467
Mailing Address - Fax:757-726-0429
Practice Address - Street 1:12 BRAEMAR DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3706
Practice Address - Country:US
Practice Address - Phone:757-232-2467
Practice Address - Fax:757-726-0429
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS5603479343900000X
VA09040102061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)