Provider Demographics
NPI:1700923471
Name:MOGA-ROACH, DIANE M (MSE, LCSW, LPC, CEAP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:MOGA-ROACH
Suffix:
Gender:F
Credentials:MSE, LCSW, LPC, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5488 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9790
Mailing Address - Country:US
Mailing Address - Phone:920-739-2212
Mailing Address - Fax:
Practice Address - Street 1:2733 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5513
Practice Address - Country:US
Practice Address - Phone:920-497-6200
Practice Address - Fax:920-497-3135
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1849-125101YP2500X
WI3562-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39742500Medicaid