Healthcare Provider Details

I. General information

NPI: 1679116636
Provider Name (Legal Business Name): DIANE FORSE, LCSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 S AUBURN AVE
RICHMOND VA
23221-2910
US

IV. Provider business mailing address

6268 CHELSEA CRES
WILLIAMSBURG VA
23188-1787
US

V. Phone/Fax

Practice location:
  • Phone: 757-603-3997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MS. DIANE M FORSE
Title or Position: OWNER/PROVIDER
Credential: LCSW
Phone: 757-603-3997