Provider Demographics
NPI:1821336082
Name:KLENKE, DIANE ELIZABETH (MA PLPC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:KLENKE
Suffix:
Gender:F
Credentials:MA PLPC
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:ELIZABETH
Other - Last Name:ZANDSTRA-KLENKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA PLPC
Mailing Address - Street 1:1011 BEDFORD LN
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1504
Mailing Address - Country:US
Mailing Address - Phone:636-226-7559
Mailing Address - Fax:
Practice Address - Street 1:1011 BEDFORD LN
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-1504
Practice Address - Country:US
Practice Address - Phone:636-226-7559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012013127101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional