Provider Demographics
NPI:1396821294
Name:BRAY, DIANA LYNN (MS)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNN
Last Name:BRAY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3410 TEN PIN LANE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-8273
Mailing Address - Country:US
Mailing Address - Phone:417-782-5865
Mailing Address - Fax:
Practice Address - Street 1:3202 MCINTOSH CIRCLE
Practice Address - Street 2:STE. LL02
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3646
Practice Address - Country:US
Practice Address - Phone:417-347-3508
Practice Address - Fax:417-347-3503
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONBCC CERT. 48566101YM0800X
MO2000158120101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO48566OtherNBCC