Provider Demographics
NPI:1558432682
Name:LICHT, DIANE M (MA, LPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:LICHT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9721
Mailing Address - Country:US
Mailing Address - Phone:973-402-9360
Mailing Address - Fax:973-402-7371
Practice Address - Street 1:550 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1168
Practice Address - Country:US
Practice Address - Phone:973-402-9360
Practice Address - Fax:973-402-7371
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00074500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health