Provider Demographics
NPI:1932183100
Name:IVANOV, DIANE JEAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:JEAN
Last Name:IVANOV
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:JEAN
Other - Last Name:RUGGIERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:538 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-3306
Mailing Address - Country:US
Mailing Address - Phone:718-496-1149
Mailing Address - Fax:
Practice Address - Street 1:77 N MAIN ST
Practice Address - Street 2:STE 4
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850-1521
Practice Address - Country:US
Practice Address - Phone:718-496-1149
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC048248001041C0700X
NYR049698-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01524574Medicaid
NJ074394Medicare ID - Type Unspecified
NY01524574Medicaid
NYN4M131Medicare ID - Type Unspecified
NJ012700Medicare ID - Type Unspecified