Provider Demographics
NPI:1518107192
Name:PALACIOS, DIANE MARIE (LPC , LISAC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:PALACIOS
Suffix:
Gender:F
Credentials:LPC , LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90336
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85066-0336
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:
Practice Address - Street 1:3001 N 33RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-5202
Practice Address - Country:US
Practice Address - Phone:602-353-0703
Practice Address - Fax:602-353-0715
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-15559101YP2500X
101YM0800X
AZLISAC-15026101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)