Individual
MRS. DIANE JEAN IVANOV
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
77 N MAIN ST, STE 4, MILLTOWN, NJ 08850-1521
(718) 496-1149
Mailing address
538 1ST AVE, NORTH BRUNSWICK, NJ 08902-3306
(718) 496-1149
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
44SC04824800
NJ
1041C0700X
Clinical Social Worker
R049698-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01524574
—
NY
Enumeration date
12/01/2005
Last updated
04/12/2017
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