Provider Demographics
NPI:1366430373
Name:MEAD, DIANE R (MSW, LISW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:R
Last Name:MEAD
Suffix:
Gender:F
Credentials:MSW, LISW
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 30024
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87190-0024
Mailing Address - Country:US
Mailing Address - Phone:505-232-8404
Mailing Address - Fax:505-884-1625
Practice Address - Street 1:2727 SAN PEDRO DR NE
Practice Address - Street 2:STE 105
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3373
Practice Address - Country:US
Practice Address - Phone:505-232-8404
Practice Address - Fax:505-884-1625
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-09221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMB2204OtherMEDICARE PROVIDER #
NM95616Medicaid
NMNMB2204OtherMEDICARE PROVIDER #