=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780868448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANNA WASIKOWSKI LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2007
-----------------------------------------------------
Last Update Date | 09/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6521 CREEDMOOR RD STE 206
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27613-3668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-244-5417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6521 CREEDMOOR RD STE 206
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27613-3668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-244-5417
-----------------------------------------------------
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 | C006562
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------