1134291552 NPI number — MS. DIANE JOY MROSS LCSW

Table of content: MS. DIANE JOY MROSS LCSW (NPI 1134291552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134291552 NPI number — MS. DIANE JOY MROSS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MROSS
Provider First Name:
DIANE
Provider Middle Name:
JOY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOODLUND
Provider Other First Name:
DIANE
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134291552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1320 W CLAIREMONT AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-4566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-834-2046
Provider Business Mailing Address Fax Number:
715-834-7563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 SOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CROSSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54601-6272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-838-9856
Provider Business Practice Location Address Fax Number:
715-838-7289
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  911-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39556000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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