Provider Demographics
NPI:1669481362
Name:JESIKIEWICZ, DIANNE (LCSWR)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:JESIKIEWICZ
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 1:227 THORN AVE
Mailing Address - Street 2:PO BOX 631
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2600
Mailing Address - Country:US
Mailing Address - Phone:716-662-2040
Mailing Address - Fax:716-662-0019
Practice Address - Street 1:2309 EGGERT RD
Practice Address - Street 2:SUITE 9
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-9200
Practice Address - Country:US
Practice Address - Phone:716-831-1856
Practice Address - Fax:716-831-0263
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0347811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000524126002OtherBLUE CROSS BLUE SHIELD
NYCC7940Medicare ID - Type Unspecified