Provider Demographics
NPI:1326624149
Name:DAVIS, DIANE (LPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DIANE JOHNSON, LPC
Mailing Address - Street 1:1114 GA HIGHWAY 96 STE C1
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-4102
Mailing Address - Country:US
Mailing Address - Phone:912-507-3362
Mailing Address - Fax:
Practice Address - Street 1:2525 MOODY ROAD STE 123
Practice Address - Street 2:
Practice Address - City:WARNER ROBBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6110
Practice Address - Country:US
Practice Address - Phone:912-507-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007072101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAPC007072OtherSTATE LICENSE