Provider Demographics
NPI:1679008726
Name:RUSSICK-KEGLOVITZ, DIANE (MA LLPC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:RUSSICK-KEGLOVITZ
Suffix:
Gender:F
Credentials:MA LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8842 E NEWFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:MI
Mailing Address - Zip Code:49421-9726
Mailing Address - Country:US
Mailing Address - Phone:162-956-2066
Mailing Address - Fax:
Practice Address - Street 1:84 S SEAWAY DR
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3841
Practice Address - Country:US
Practice Address - Phone:231-733-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015994101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional