=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700923471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE M MOGA-ROACH MSE, LCSW, LPC, CEAP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2733 S RIDGE RD
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54304-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-497-6200
-----------------------------------------------------
Fax | 920-497-3135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W5488 QUARRY RD
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54913-9790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-739-2212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1849-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3562-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------