=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912201112
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE DALENE DENICE KLINE-GORNEY LBSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2011
-----------------------------------------------------
Last Update Date | 01/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 GRIFFIN RD
-----------------------------------------------------
City | WEST BRANCH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48661-9251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-345-5571
-----------------------------------------------------
Fax | 989-345-4111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 310
-----------------------------------------------------
City | TAWAS CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48764-0310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-362-8636
-----------------------------------------------------
Fax | 989-362-7800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6802077949
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------