Provider Demographics
NPI:1356645626
Name:WAACK, DIANE JEAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:JEAN
Last Name:WAACK
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 1:16831 TRAIL VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-4346
Mailing Address - Country:US
Mailing Address - Phone:303-471-1769
Mailing Address - Fax:
Practice Address - Street 1:16831 TRAIL VIEW CIR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-4346
Practice Address - Country:US
Practice Address - Phone:303-471-1769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO516OtherLCSW