Provider Demographics
NPI:1730393794
Name:SMITH, DIANE M (LPC, NBCC, CADC)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC, NBCC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7848 HIXON RD
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9112
Mailing Address - Country:US
Mailing Address - Phone:920-539-1160
Mailing Address - Fax:
Practice Address - Street 1:7848 HIXON RD
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9112
Practice Address - Country:US
Practice Address - Phone:920-539-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2746OtherLPC