MEDICARE: DIANA J WALZ LCSW

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	SW005946	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00130709	OTHER	MO	RR MEDICARE

General Provider Information

NPI Number	:	1023076841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA J WALZ LCSW

Provider Business Mailing Address
First Line	:	PO BOX 7687
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65205-7687
Country	:	US
Telephone Number	:	573-882-2259
Fax Number	:	573-884-8526

Provider Business Practice Location Address
First Line	:	601 BUSINESS LOOP 70 W
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-2546
Country	:	US
Telephone Number	:	573-884-1400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	07/08/2007

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