Provider Demographics
NPI:1891107603
Name:BURROUGHS, DIANE C (LCSW, LSCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:LCSW, LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 CRANSWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6339
Mailing Address - Country:US
Mailing Address - Phone:719-650-0812
Mailing Address - Fax:
Practice Address - Street 1:3555 CRANSWOOD WAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6339
Practice Address - Country:US
Practice Address - Phone:719-650-0812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW009896461041C0700X
KS10561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO451657851OtherFEIN