Healthcare Provider Details

I. General information

NPI: 1083652002
Provider Name (Legal Business Name): DIANE M DIGERONIMO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 OCEAN AVE STE 107
MELBOURNE BEACH FL
32951-2569
US

IV. Provider business mailing address

321 OCEAN AVE STE 107
MELBOURNE BEACH FL
32951-2569
US

V. Phone/Fax

Practice location:
  • Phone: 321-230-3023
  • Fax:
Mailing address:
  • Phone: 321-230-3023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW0002181
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: