Provider Demographics
NPI:1003399767
Name:WOOD, DIANE PATRICE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:PATRICE
Last Name:WOOD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:PREBLE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:29A EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-2556
Mailing Address - Country:US
Mailing Address - Phone:978-675-9501
Mailing Address - Fax:978-283-1588
Practice Address - Street 1:29A EMERSON AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-2556
Practice Address - Country:US
Practice Address - Phone:978-675-9501
Practice Address - Fax:978-283-1588
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10264291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical