Provider Demographics
NPI:1750433629
Name:SMITH, DIANA MARIE (PHD, LPC-MH)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD, LPC-MH
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:MARIE
Other - Last Name:STYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC MH
Mailing Address - Street 1:6613 EASTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BLACK HAWK
Mailing Address - State:SD
Mailing Address - Zip Code:57718-8335
Mailing Address - Country:US
Mailing Address - Phone:605-347-7560
Mailing Address - Fax:605-718-7595
Practice Address - Street 1:6613 EASTRIDGE RD
Practice Address - Street 2:
Practice Address - City:BLACK HAWK
Practice Address - State:SD
Practice Address - Zip Code:57718-8335
Practice Address - Country:US
Practice Address - Phone:605-431-8595
Practice Address - Fax:605-431-8595
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC MH 2025101Y00000X, 101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575393Medicaid
SD4997637OtherDAKOTA CARE
SD4997637OtherWELLMARK BLUE CROSS