Provider Demographics
NPI:1245795608
Name:MICHELL, DIANA (LMHC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MICHELL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JOHNSON AVE STE C5
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2669
Mailing Address - Country:US
Mailing Address - Phone:631-533-0315
Mailing Address - Fax:
Practice Address - Street 1:600 JOHNSON AVE STE C5
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2669
Practice Address - Country:US
Practice Address - Phone:631-533-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007639101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional