Provider Demographics
NPI:1497704449
Name:MOUSSEAU, DIANA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:MOUSSEAU
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 1:6360 E BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9732
Mailing Address - Country:US
Mailing Address - Phone:850-910-2523
Mailing Address - Fax:
Practice Address - Street 1:1351 SOMERSET AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1030
Practice Address - Country:US
Practice Address - Phone:850-910-2523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW115921041C0700X
MI6801080235104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical