Basic Information
| Provider Information | |||||||||
| NPI: | 1518107192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALACIOS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC , LISAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 90336 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850660336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022797655 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3001 N 33RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850175202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023530703 | ||||||||
| FaxNumber: | 6023530715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-15026 | AZ | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC-15559 | AZ | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.