Provider Demographics
NPI:1134255276
Name:WAKELEY, DIANE M (PCC-S, LICDC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:WAKELEY
Suffix:
Gender:F
Credentials:PCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11106 KIMMERIDGE TRL
Mailing Address - Street 2:#4B
Mailing Address - City:NEWBURY
Mailing Address - State:OH
Mailing Address - Zip Code:44065-9683
Mailing Address - Country:US
Mailing Address - Phone:216-288-6223
Mailing Address - Fax:
Practice Address - Street 1:8351 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5749
Practice Address - Country:US
Practice Address - Phone:216-839-2273
Practice Address - Fax:216-896-0735
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH933513101YA0400X
OHE-1976101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)