Provider Demographics
NPI:1073673109
Name:DAVIS, DIANE KAYE (MSED, NCC, LCPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KAYE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSED, NCC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-2666
Mailing Address - Country:US
Mailing Address - Phone:618-687-5353
Mailing Address - Fax:618-687-5077
Practice Address - Street 1:608 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2666
Practice Address - Country:US
Practice Address - Phone:618-687-5353
Practice Address - Fax:618-687-5077
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional