Provider Demographics
NPI:1023339967
Name:DIANE MENKE PENCE, LLC
Entity type:Organization
Organization Name:DIANE MENKE PENCE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MENKE
Authorized Official - Last Name:PENCE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:812-876-6322
Mailing Address - Street 1:1522 N LIMESTONE DR
Mailing Address - Street 2:
Mailing Address - City:ELLETTSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47429-9363
Mailing Address - Country:US
Mailing Address - Phone:812-876-6322
Mailing Address - Fax:
Practice Address - Street 1:205 N COLLEGE AVE
Practice Address - Street 2:STE 613
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3950
Practice Address - Country:US
Practice Address - Phone:812-333-3440
Practice Address - Fax:812-333-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002125A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN158893992OtherNPI INDIVUDAL