Provider Demographics
NPI:1477903888
Name:PARK, DIANE SPRAGUE (LSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:SPRAGUE
Last Name:PARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:SPRAGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:432 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-3247
Mailing Address - Country:US
Mailing Address - Phone:419-289-8100
Mailing Address - Fax:
Practice Address - Street 1:432 CENTER ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3247
Practice Address - Country:US
Practice Address - Phone:419-289-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 0020964104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker