=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497704449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA MOUSSEAU LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 08/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1351 SOMERSET AVE
-----------------------------------------------------
City | GROSSE POINTE PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48230-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-910-2523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6360 E BAY BLVD
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32563-9732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-910-2523
-----------------------------------------------------
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 | SW11592
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6801080235
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------