MEDICARE: DIANE E FERREIRA LPC

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	101YM0800X	Mental Health Counselor	LPC00910	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	179857	OTHER		CPRP

General Provider Information

NPI Number	:	1700012556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE E FERREIRA LPC

Provider Business Mailing Address
First Line	:	1440 SARGENT AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2329
Country	:	US
Telephone Number	:	651-214-3502
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 SARGENT AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2329
Country	:	US
Telephone Number	:	651-214-3502
Fax Number	:

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

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	10/25/2010

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