Provider Demographics
NPI:1962506337
Name:MACKEY, DIANE (NBCC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MACKEY
Suffix:
Gender:F
Credentials:NBCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 12TH ST. SUITE 22
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439
Mailing Address - Country:US
Mailing Address - Phone:541-921-1497
Mailing Address - Fax:
Practice Address - Street 1:1525 12TH ST STE 22
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-8487
Practice Address - Country:US
Practice Address - Phone:541-902-0408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL35925101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164907OtherOMAP GROUP