Provider Demographics
NPI:1194939090
Name:KWIECINSKI, DIANA (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:KWIECINSKI
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1074
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-6074
Mailing Address - Country:US
Mailing Address - Phone:908-881-4368
Mailing Address - Fax:
Practice Address - Street 1:1040 KINGS HWY N
Practice Address - Street 2:SUITE 100
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1908
Practice Address - Country:US
Practice Address - Phone:856-414-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC013040001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC01304000OtherLIC CLINICAL SOCIAL WORKE
NJ016779Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION N