Basic Information
| Provider Information | |||||||||
| NPI: | 1902878960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCUTCHEON | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSWC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1945 | ||||||||
| Address2: | BROOK LANE HEALTH SERVICES | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330331 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Practice Location | |||||||||
| Address1: | 18714 N VILLAGE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217422454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330331 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 13448 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 986965400 | 05 | MD | MEDICAID |