Healthcare Provider Details

I. General information

NPI: 1689612855
Provider Name (Legal Business Name): DIANA L SPURLOCK MSW, LCSW, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N US HIGHWAY 89
PRESCOTT AZ
86313-5001
US

IV. Provider business mailing address

1050 S 16TH PL
COTTONWOOD AZ
86326-6993
US

V. Phone/Fax

Practice location:
  • Phone: 800-949-1005
  • Fax: 928-776-6125
Mailing address:
  • Phone: 928-649-1802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 4157
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLISW I4257
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: