Provider Demographics
NPI:1710497078
Name:DIACZENKO, AMANDA MAE (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAE
Last Name:DIACZENKO
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 SENECA DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-8833
Mailing Address - Country:US
Mailing Address - Phone:681-220-9366
Mailing Address - Fax:
Practice Address - Street 1:218 SENECA DR
Practice Address - Street 2:
Practice Address - City:MOUNT HOPE
Practice Address - State:WV
Practice Address - Zip Code:25880-8833
Practice Address - Country:US
Practice Address - Phone:681-220-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-01
Last Update Date:2017-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00943930104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker