Provider Demographics
NPI:1265095913
Name:D'AGOSTINO, DIANE L (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:D'AGOSTINO
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 1:1 N WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-1875
Mailing Address - Country:US
Mailing Address - Phone:609-567-0200
Mailing Address - Fax:609-567-1169
Practice Address - Street 1:651 HIGH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-2737
Practice Address - Country:US
Practice Address - Phone:609-386-0775
Practice Address - Fax:609-386-4372
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055992001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical