Healthcare Provider Details

I. General information

NPI: 1568478543
Provider Name (Legal Business Name): DIANE MARIE KUNKEL LPC/NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 US HIGHWAY 71 SUITE G
PINEVILLE MO
64856-9310
US

IV. Provider business mailing address

412 US HIGHWAY 71 SUITE G
PINEVILLE MO
64856-9310
US

V. Phone/Fax

Practice location:
  • Phone: 417-223-2823
  • Fax: 417-223-2822
Mailing address:
  • Phone: 417-223-2823
  • Fax: 417-223-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2004033323
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: