Provider Demographics
NPI:1881605665
Name:WILSON, DIANE BROADY (LPC)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:BROADY
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:O'MEARA
Other - Last Name:BROADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:1411 E AMARILLO BLVD
Mailing Address - Street 2:1411 AMARILLO BLVD., EAST, J.O. WYATT CLINIC
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79107-5555
Mailing Address - Country:US
Mailing Address - Phone:806-351-7212
Mailing Address - Fax:806-351-7284
Practice Address - Street 1:1411 E AMARILLO BLVD
Practice Address - Street 2:1411 AMARILLO BLVD., EAST, J.O. WYATT CLINIC
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79107-5555
Practice Address - Country:US
Practice Address - Phone:806-351-7212
Practice Address - Fax:806-351-7284
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16692101YM0800X
101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144810202Medicaid