Provider Demographics
NPI:1548269475
Name:BAUMBACH, DIANE J (LISW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:J
Last Name:BAUMBACH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 KIRKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-4754
Mailing Address - Country:US
Mailing Address - Phone:319-351-6654
Mailing Address - Fax:319-339-0905
Practice Address - Street 1:320 KIRKWOOD AVE
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4754
Practice Address - Country:US
Practice Address - Phone:319-351-6654
Practice Address - Fax:319-339-0905
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01865OtherBLUE CROSS/BLUE SHIELD OF
IA421501340Y1R3P8Medicaid
IA421501340Y1R3P8Medicaid