Provider Demographics
NPI:1528135183
Name:DAHLBOM, DIANNE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:
Last Name:DAHLBOM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BISHOPS FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8809
Mailing Address - Country:US
Mailing Address - Phone:781-893-3028
Mailing Address - Fax:
Practice Address - Street 1:4 MUZZEY ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5220
Practice Address - Country:US
Practice Address - Phone:339-927-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10294031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07722OtherBLUE CROSS BLUE SHIELD
MAP74001Medicare UPIN
P22885Medicare ID - Type Unspecified