Provider Demographics
NPI:1871666842
Name:BODDY, DIANE JOHNSON (LPC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:JOHNSON
Last Name:BODDY
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 1:1401 HOLLIDAY ST STE 218
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-7143
Mailing Address - Country:US
Mailing Address - Phone:940-322-3434
Mailing Address - Fax:940-322-0505
Practice Address - Street 1:1401 HOLLIDAY ST STE 218
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-7143
Practice Address - Country:US
Practice Address - Phone:940-322-3434
Practice Address - Fax:940-322-0505
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15172101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health