=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033217955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE KAY BAUMBACH LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 07/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2755 10TH AVE N
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-738-0888
-----------------------------------------------------
Fax | 701-757-1431
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7055 148TH AVE NE
-----------------------------------------------------
City | GRAFTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58237-9054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-791-5669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2971
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------