Provider Demographics
NPI:1508843780
Name:PHINNEY, DIANE H (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:PHINNEY
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 1:815 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-5940
Mailing Address - Country:US
Mailing Address - Phone:352-341-3435
Mailing Address - Fax:352-291-9536
Practice Address - Street 1:815 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-5940
Practice Address - Country:US
Practice Address - Phone:352-341-3435
Practice Address - Fax:352-291-9536
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0020671041C0700X
FLSW117771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO49625743Medicaid
MO493625701Medicaid
MO493625750Medicaid
MO493625727Medicaid
MO493625719Medicaid
MS493625735Medicaid
MO825402318Medicare ID - Type UnspecifiedSEMO CTC
MO49625743Medicaid