MEDICARE: DIANE O'NEILL LISW LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	9672	SC

General Provider Information

NPI Number	:	1003177395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANE O'NEILL LISW LLC

Provider Business Mailing Address
First Line	:	852 GOLD HILL RD
Second Line	:	SUITE 206
City	:	FORT MILL
State	:	SC
Zip	:	29708-7976
Country	:	US
Telephone Number	:	803-619-9103
Fax Number	:	866-585-6452

Provider Business Practice Location Address
First Line	:	852 GOLD HILL RD
Second Line	:	SUITE 206
City	:	FORT MILL
State	:	SC
Zip	:	29708-7976
Country	:	US
Telephone Number	:	803-619-9103
Fax Number	:	866-585-6452

Authorized Official
Title or Position	:	SOLE MEMBER/MANAGER
Name	:	DIANE O'NEILL
Credential	:	LISW
Telephone Number	:	803-619-9103

Provider Enumeration Date	:	06/03/2012
Last Update Date	:	06/03/2012

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