Provider Demographics
NPI:1538472626
Name:COLL, DIANE (LPC, MT-BC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:COLL
Suffix:
Gender:F
Credentials:LPC, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 CHARLTON TRCE SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2967
Mailing Address - Country:US
Mailing Address - Phone:770-548-4395
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD
Practice Address - Street 2:BUILDING 9, SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-548-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005810101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional