Provider Demographics
NPI:1477561926
Name:MUFSON, DIANE WEISS (MA)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:WEISS
Last Name:MUFSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:CECILE
Other - Last Name:MUFSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:845 4TH AVE
Mailing Address - Street 2:STE 301 APT INC
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1470
Mailing Address - Country:US
Mailing Address - Phone:304-523-8911
Mailing Address - Fax:304-523-8912
Practice Address - Street 1:845 4TH AVE
Practice Address - Street 2:STE 301
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1470
Practice Address - Country:US
Practice Address - Phone:304-523-8911
Practice Address - Fax:304-523-8912
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV224103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01635282000Medicaid