Provider Demographics
NPI:1720120942
Name:KEITH, DIANE MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:KEITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 COOPER DR
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-8114
Mailing Address - Country:US
Mailing Address - Phone:816-331-1563
Mailing Address - Fax:
Practice Address - Street 1:8510 WORNALL RD
Practice Address - Street 2:LIFE CENTER
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-2918
Practice Address - Country:US
Practice Address - Phone:816-361-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002032331101YP2500X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool