Healthcare Provider Details

I. General information

NPI: 1710922216
Provider Name (Legal Business Name): DIANE JEAN VINSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4209 WEDGEWOOD RD
ENID OK
73703-3540
US

IV. Provider business mailing address

1115 HARBER RD
GROVE OK
74344-7918
US

V. Phone/Fax

Practice location:
  • Phone: 580-340-4709
  • Fax:
Mailing address:
  • Phone: 918-786-4434
  • Fax: 918-786-4435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1581
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: