Healthcare Provider Details

I. General information

NPI: 1497704449
Provider Name (Legal Business Name): DIANA MOUSSEAU LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 SOMERSET AVE
GROSSE POINTE PARK MI
48230-1030
US

IV. Provider business mailing address

6360 E BAY BLVD
GULF BREEZE FL
32563-9732
US

V. Phone/Fax

Practice location:
  • Phone: 850-910-2523
  • Fax:
Mailing address:
  • Phone: 850-910-2523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11592
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801080235
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: