MEDICARE: MS. DIANE M DATZ LISW-S

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	I0009482	OH

General Provider Information

NPI Number	:	1396119863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE M DATZ LISW-S

Provider Business Mailing Address
First Line	:	4218 ARBUTUS AVE
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-3115
Country	:	US
Telephone Number	:	614-600-9867
Fax Number	:

Provider Business Practice Location Address
First Line	:	4218 ARBUTUS AVE
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-3115
Country	:	US
Telephone Number	:	614-600-9867
Fax Number	:

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

Provider Enumeration Date	:	11/21/2015
Last Update Date	:	11/21/2015

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