Provider Demographics
NPI:1619062049
Name:GEISEN, DIANE L (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:L
Last Name:GEISEN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MISS
Other - First Name:DIANE
Other - Middle Name:L
Other - Last Name:DREESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:1220 CENTRAL AVE STE 1-A
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-3752
Mailing Address - Country:US
Mailing Address - Phone:406-727-2512
Mailing Address - Fax:406-727-7451
Practice Address - Street 1:2211 5TH AVE N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401
Practice Address - Country:US
Practice Address - Phone:406-452-6655
Practice Address - Fax:406-452-6561
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT639 LCSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0503642Medicaid