Healthcare Provider Details

I. General information

NPI: 1518107192
Provider Name (Legal Business Name): DIANE MARIE PALACIOS LPC , LISAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N 33RD AVE
PHOENIX AZ
85017-5202
US

IV. Provider business mailing address

PO BOX 90336
PHOENIX AZ
85066-0336
US

V. Phone/Fax

Practice location:
  • Phone: 602-353-0703
  • Fax: 602-353-0715
Mailing address:
  • Phone: 602-279-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-15026
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-15559
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: