Provider Demographics
NPI:1134246812
Name:BAILEY, DIANE P (LCSW)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:P
Last Name:BAILEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 S. QUEENS CT.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-569-2398
Mailing Address - Fax:
Practice Address - Street 1:2021 S. WAVERLY
Practice Address - Street 2:SUITE 700
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:414-569-2398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0008841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498589902Medicaid
834290041Medicare PIN