Provider Demographics
NPI:1013116797
Name:HOMER, DIANE BETH (LICSW)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:BETH
Last Name:HOMER
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 1:33 OLD CONNECTICUT PATH
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-2810
Mailing Address - Country:US
Mailing Address - Phone:508-358-4030
Mailing Address - Fax:
Practice Address - Street 1:33 OLD CONNECTICUT PATH
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-2810
Practice Address - Country:US
Practice Address - Phone:508-358-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1034951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical