Provider Demographics
NPI:1457433146
Name:WALLACE, DIANA KAY (LIMHP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:KAY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 S JEFFERS ST STE 7
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5370
Mailing Address - Country:US
Mailing Address - Phone:308-221-2141
Mailing Address - Fax:308-221-2141
Practice Address - Street 1:518 S JEFFERS ST STE 7
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5370
Practice Address - Country:US
Practice Address - Phone:308-221-2141
Practice Address - Fax:308-221-2141
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE700101Y00000X
NE583101YM0800X
NE265106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE82473OtherBLUE CROSS BLUE SHIELD OF NEBRASKA
NE10025816000Medicaid