MEDICARE: DIANE MARIE PERRY LICSW

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	11584	MN

General Provider Information

NPI Number	:	1598486177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MARIE PERRY LICSW

Provider Business Mailing Address
First Line	:	210 ATHENS WAY STE 200
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37228-1308
Country	:	US
Telephone Number	:	612-578-3976
Fax Number	:

Provider Business Practice Location Address
First Line	:	6200 SHINGLE CREEK PKWY STE 250
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55430-2107
Country	:	US
Telephone Number	:	612-578-3976
Fax Number	:	763-544-0984

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

Provider Enumeration Date	:	09/12/2022
Last Update Date	:	09/12/2022

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