Provider Demographics
NPI:1659414050
Name:GOGAN, DIANE M (LIC AC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:GOGAN
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2844
Mailing Address - Country:US
Mailing Address - Phone:617-381-0101
Mailing Address - Fax:
Practice Address - Street 1:THE CENTER FOR WELL-BEING
Practice Address - Street 2:153A MAIN STREET
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149
Practice Address - Country:US
Practice Address - Phone:617-381-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211690171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist