Provider Demographics
NPI:1881262343
Name:BOODY, DIANE IRENE
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:IRENE
Last Name:BOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5356 LANDRUM DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-3765
Mailing Address - Country:US
Mailing Address - Phone:314-477-3714
Mailing Address - Fax:
Practice Address - Street 1:5356 LANDRUM DRIVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234
Practice Address - Country:US
Practice Address - Phone:314-477-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003242A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health