Provider Demographics
NPI:1477892925
Name:LIVELY, DIANA LYNN (MS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:LIVELY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14966 W GRANDVIEW RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1120
Mailing Address - Country:US
Mailing Address - Phone:918-931-1971
Mailing Address - Fax:
Practice Address - Street 1:109 W 2ND ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4723
Practice Address - Country:US
Practice Address - Phone:918-431-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)