Provider Demographics
NPI:1699899906
Name:MCDONALD-GOETZMANN, DIANE (MSW, LISW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MCDONALD-GOETZMANN
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 1:3501 HARRY LANGDON BLVD
Mailing Address - Street 2:CHILD HEALTH SPECIALTY CLINICS
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-7837
Mailing Address - Country:US
Mailing Address - Phone:712-309-0041
Mailing Address - Fax:712-309-0044
Practice Address - Street 1:3501 HARRY LANGDON BLVD
Practice Address - Street 2:CHILD HEALTH SPECIALTY CLINICS
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-7837
Practice Address - Country:US
Practice Address - Phone:712-309-0041
Practice Address - Fax:712-309-0044
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA028311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01055OtherWELLMARK BCBS
IAI19741Medicare PIN