Basic Information
| Provider Information | |||||||||
| NPI: | 1730272691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIANA | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 WAYNE AVE | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818438079 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 LEDGEWOOD PL | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818716550 | ||||||||
| FaxNumber: | 7818715973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 10226475 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.