Provider Demographics
NPI:1649425224
Name:WAIT, DIANE (MA, LPC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WAIT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 381
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-0381
Mailing Address - Country:US
Mailing Address - Phone:336-846-4491
Mailing Address - Fax:336-846-4927
Practice Address - Street 1:514 MCCONNELL ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9789
Practice Address - Country:US
Practice Address - Phone:336-846-4491
Practice Address - Fax:336-846-4927
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104109Medicaid