Provider Demographics
NPI:1598486177
Name:PERRY, DIANE MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:PERRY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ATHENS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-1308
Mailing Address - Country:US
Mailing Address - Phone:612-578-3976
Mailing Address - Fax:
Practice Address - Street 1:6200 SHINGLE CREEK PKWY STE 250
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2107
Practice Address - Country:US
Practice Address - Phone:612-578-3976
Practice Address - Fax:763-544-0984
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical