Provider Demographics
NPI:1588682116
Name:THOMAS, E DIANE (MS, LCSW)
Entity Type:Individual
Prefix:MS
First Name:E
Middle Name:DIANE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2917
Mailing Address - Country:US
Mailing Address - Phone:260-422-3034
Mailing Address - Fax:260-422-3691
Practice Address - Street 1:509 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2917
Practice Address - Country:US
Practice Address - Phone:260-422-3034
Practice Address - Fax:260-422-3691
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002561A101YM0800X
IN35001087A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000183262OtherBC-BS