Provider Demographics
NPI:1639718620
Name:KLEBANOFF, DIANA (LCSWR)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KLEBANOFF
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 NORTH LOOP
Mailing Address - Street 2:
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-1921
Mailing Address - Country:US
Mailing Address - Phone:845-876-5550
Mailing Address - Fax:
Practice Address - Street 1:1 COMMONS DR
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5149
Practice Address - Country:US
Practice Address - Phone:845-336-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0265111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical