Provider Demographics
NPI:1508808148
Name:COURSON, DIANA (BS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:COURSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18356 NW 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2934
Mailing Address - Country:US
Mailing Address - Phone:786-953-4612
Mailing Address - Fax:786-953-8534
Practice Address - Street 1:17567 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-5435
Practice Address - Country:US
Practice Address - Phone:786-293-9544
Practice Address - Fax:786-293-9594
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL320071000Medicaid