Basic Information
| Provider Information | |||||||||
| NPI: | 1902492697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIARRA | ||||||||
| FirstName: | SORY IBRAHIM | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410310 | ||||||||
| Practice Location | |||||||||
| Address1: | 498 NW 18TH ST BLDG 417 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473742851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653738704 | ||||||||
| FaxNumber: | 7654882609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2020 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 99100961A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.