Provider Demographics
NPI:1558348938
Name:HADDON, DIANE V (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:V
Last Name:HADDON
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N HIGGINS AVENUE
Mailing Address - Street 2:SUITE 324
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802
Mailing Address - Country:US
Mailing Address - Phone:406-721-6144
Mailing Address - Fax:406-721-6709
Practice Address - Street 1:210 N HIGGINS AVENUE
Practice Address - Street 2:SUITE 324
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-721-6144
Practice Address - Fax:406-721-6709
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT289LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000502203Medicaid