Provider Demographics
NPI:1740372838
Name:SURRELL, DIANA RAE (LMSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:RAE
Last Name:SURRELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1767
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1767
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:6728 VINING RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-9784
Practice Address - Country:US
Practice Address - Phone:616-225-8220
Practice Address - Fax:616-225-8226
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801083023104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid