Provider Demographics
NPI:1467602623
Name:BRAZILL, DIANE KAY (MSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:KAY
Last Name:BRAZILL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:KAY
Other - Last Name:MCGRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 N 6TH AVE E
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1952
Mailing Address - Country:US
Mailing Address - Phone:218-249-7000
Mailing Address - Fax:218-249-7050
Practice Address - Street 1:220 N 6TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1952
Practice Address - Country:US
Practice Address - Phone:218-249-7000
Practice Address - Fax:218-249-7050
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127126-121104100000X
MN183611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker