Provider Demographics
NPI:1861516569
Name:LIPPENCOTT, DIANA RAE (MA, LSW, LICDC)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:RAE
Last Name:LIPPENCOTT
Suffix:
Gender:F
Credentials:MA, LSW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 GLENKIRK DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-9464
Mailing Address - Country:US
Mailing Address - Phone:614-575-2994
Mailing Address - Fax:
Practice Address - Street 1:4429 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9228
Practice Address - Country:US
Practice Address - Phone:614-836-2434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH954183101YA0400X
OHS0014954104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker