Provider Demographics
NPI:1720102239
Name:SUDA, DIANE STARK (MSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:STARK
Last Name:SUDA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 SHADYSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481
Mailing Address - Country:US
Mailing Address - Phone:201-891-5148
Mailing Address - Fax:
Practice Address - Street 1:10 FRANKLIN TURNPIKE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463
Practice Address - Country:US
Practice Address - Phone:201-612-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC001901001041C0700X
NJ26NR03997100163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00114374OtherRAILROAD MEDICARE
54654540Medicare ID - Type Unspecified