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
State | License ID | Taxonomies |
---|---|---|
AZ | LPC-15559 | 101YP2500X |
101YM0800X | ||
AZ | LISAC-15026 | 101YA0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |