Provider Demographics
NPI:1295361863
Name:MORYL, DIANA K (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:K
Last Name:MORYL
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 1:6910 N MAIN ST
Mailing Address - Street 2:STE 13L, BOX 52
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530
Mailing Address - Country:US
Mailing Address - Phone:574-231-6766
Mailing Address - Fax:833-249-2411
Practice Address - Street 1:6910 N MAIN ST UNIT 13L
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9681
Practice Address - Country:US
Practice Address - Phone:574-231-6766
Practice Address - Fax:833-249-2411
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001715A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE