Provider Demographics
NPI:1902492697
Name:DIARRA, SORY IBRAHIM (LSW)
Entity Type:Individual
Prefix:
First Name:SORY IBRAHIM
Middle Name:
Last Name:DIARRA
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0310
Practice Address - Street 1:498 NW 18TH ST BLDG 417
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-2851
Practice Address - Country:US
Practice Address - Phone:765-373-8704
Practice Address - Fax:765-488-2609
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99100961A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker