Provider Demographics
NPI:1639374457
Name:GRADUS, DIANA REH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:REH
Last Name:GRADUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3653
Mailing Address - Country:US
Mailing Address - Phone:718-768-2313
Mailing Address - Fax:
Practice Address - Street 1:423 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3653
Practice Address - Country:US
Practice Address - Phone:718-768-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR032631-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN94743Medicare ID - Type Unspecified