Provider Demographics
NPI:1790176576
Name:GORES, DIANE J (LPC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:J
Last Name:GORES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 LAKE HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9710
Mailing Address - Country:US
Mailing Address - Phone:912-713-4684
Mailing Address - Fax:
Practice Address - Street 1:127 LAKE HOUSE RD
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9710
Practice Address - Country:US
Practice Address - Phone:912-713-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-14
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007991101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional