Provider Demographics
NPI:1699824748
Name:HOUSTON, DIANE (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 899
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-0899
Mailing Address - Country:US
Mailing Address - Phone:401-364-7705
Mailing Address - Fax:401-364-3310
Practice Address - Street 1:4705 OLD POST RD UNIT A
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-1842
Practice Address - Country:US
Practice Address - Phone:401-789-1367
Practice Address - Fax:401-364-3310
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW009041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI709001889OtherMEDICARE GATEWAY HEALTHCARE
RI1699824748OtherBLUE CROSS BLUE SHIELD RI
RIDH03900Medicaid
RIDH03900Medicaid