Provider Demographics
NPI:1619978046
Name:GATES, DIANE K (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:GATES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:K
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:889 DEWING RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05457-9434
Mailing Address - Country:US
Mailing Address - Phone:802-285-6511
Mailing Address - Fax:802-285-6508
Practice Address - Street 1:889 DEWING RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VT
Practice Address - Zip Code:05457-9434
Practice Address - Country:US
Practice Address - Phone:802-285-6511
Practice Address - Fax:802-285-6508
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900009891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT382112OtherMVP
VT030215982OtherMAGELLAN
VT1011242Medicaid
VT00068481OtherBCBS
VT030215982OtherMAGELLAN
VT1011242Medicaid