Provider Demographics
NPI:1073648143
Name:SPADE, DIANE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:SPADE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-3245
Mailing Address - Country:US
Mailing Address - Phone:906-864-9830
Mailing Address - Fax:906-864-9831
Practice Address - Street 1:908 2ND ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-3245
Practice Address - Country:US
Practice Address - Phone:906-864-9830
Practice Address - Fax:906-864-9831
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010032101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI730195Medicaid
MI382143740OtherTAX ID NUMBER