Provider Demographics
NPI:1396765137
Name:BURKS, DIANE ARNOLD (MS)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ARNOLD
Last Name:BURKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 N HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-3684
Mailing Address - Country:US
Mailing Address - Phone:317-381-0355
Mailing Address - Fax:317-381-0356
Practice Address - Street 1:618 N HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-3684
Practice Address - Country:US
Practice Address - Phone:317-381-0355
Practice Address - Fax:317-381-0356
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002013A1041C0700X
IN35000741A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100177270Medicaid
IN292726000OtherMAGELLAN
IN7437447OtherAETNA
IN000000222728OtherANTHEM PPO, TRADITIONAL