Provider Demographics
NPI:1831255157
Name:DIVER, ANGELA DAWN (LISW, LICDC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:DIVER
Suffix:
Gender:F
Credentials:LISW, LICDC
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:DAWN
Other - Last Name:KRAFT-DIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 S BREIEL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-5158
Mailing Address - Country:US
Mailing Address - Phone:513-423-3327
Mailing Address - Fax:513-423-3676
Practice Address - Street 1:220 S BREIEL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5158
Practice Address - Country:US
Practice Address - Phone:513-423-3327
Practice Address - Fax:513-423-3676
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI70921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11661621OtherCAQH CREDENTIALING