Provider Demographics
NPI:1124864269
Name:WING, DIANNELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:DIANNELLE
Middle Name:
Last Name:WING
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 1:373 COMMONWEALTH RD APT 119
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-5135
Mailing Address - Country:US
Mailing Address - Phone:917-743-5855
Mailing Address - Fax:
Practice Address - Street 1:373 COMMONWEALTH RD APT 119
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-5135
Practice Address - Country:US
Practice Address - Phone:917-743-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW228130104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker