Healthcare Provider Details

I. General information

NPI: 1740918457
Provider Name (Legal Business Name): DIANA LESMES PALACIOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 VALLEY RD APT A1
CHAMPAIGN IL
61820-7127
US

IV. Provider business mailing address

1613 VALLEY RD APT A1
CHAMPAIGN IL
61820-7127
US

V. Phone/Fax

Practice location:
  • Phone: 217-721-1944
  • Fax:
Mailing address:
  • Phone: 217-721-1944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: