Provider Demographics
NPI:1861757239
Name:DIANE, DEBRA (LCSW)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:DIANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 N STATE ROAD 7 STE 201
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5839
Mailing Address - Country:US
Mailing Address - Phone:954-777-1617
Mailing Address - Fax:954-497-3857
Practice Address - Street 1:2900 W PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2519
Practice Address - Country:US
Practice Address - Phone:954-731-5100
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW10293101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health