Healthcare Provider Details

I. General information

NPI: 1912218447
Provider Name (Legal Business Name): DIANE MOBLEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 LESLIE LANE
PURDY MO
65734-0414
US

IV. Provider business mailing address

PO BOX 414 103 LESLIE LANE
PURDY MO
65734-0414
US

V. Phone/Fax

Practice location:
  • Phone: 417-461-4001
  • Fax:
Mailing address:
  • Phone: 417-461-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2010018850
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: