Provider Demographics
NPI:1952552309
Name:CHAN, WAI WUN DIANA (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:WAI WUN DIANA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:793 ERICKSEN AVE NE STE 123
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1877
Mailing Address - Country:US
Mailing Address - Phone:206-207-5375
Mailing Address - Fax:206-338-9906
Practice Address - Street 1:793 ERICKSEN AVE NE STE 123
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1877
Practice Address - Country:US
Practice Address - Phone:206-207-5375
Practice Address - Fax:206-338-9906
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60193264101YM0800X, 101YP2500X, 104100000X
WALW 601932641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2048825Medicaid