Provider Demographics
NPI:1619079746
Name:LAVELY, DIANE (LCSW BCD MSWAC)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:LAVELY
Suffix:
Gender:F
Credentials:LCSW BCD MSWAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 E TAHQUITZ CANYON WAY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262
Mailing Address - Country:US
Mailing Address - Phone:760-416-7846
Mailing Address - Fax:760-416-2061
Practice Address - Street 1:2225 E TAHQUITZ CANYON WAY
Practice Address - Street 2:SUITE 5
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262
Practice Address - Country:US
Practice Address - Phone:760-416-7846
Practice Address - Fax:760-416-2061
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSWACB5417101YA0400X
CALCS157731041C0700X
ORLCSW12201041C0700X
BCD273211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ38328ZMedicare UPIN
ZZZ38328ZMedicare ID - Type Unspecified