Provider Demographics
NPI:1215060892
Name:DIGIACOMO-CANELLAS, DIANA (LCSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DIGIACOMO-CANELLAS
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 1:231 NW 69TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2390
Mailing Address - Country:US
Mailing Address - Phone:860-324-6841
Mailing Address - Fax:
Practice Address - Street 1:980 N FEDERAL HWY STE 110
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-2704
Practice Address - Country:US
Practice Address - Phone:860-324-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0064221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1942393814Medicaid
CT004161725Medicaid
CT1174624423OtherFACILITY NPI NUMBER