Healthcare Provider Details

I. General information

NPI: 1750433629
Provider Name (Legal Business Name): DIANA MARIE SMITH PHD, LPC-MH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANA MARIE STYLES LPC MH

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6613 EASTRIDGE RD
BLACK HAWK SD
57718-8335
US

IV. Provider business mailing address

6613 EASTRIDGE RD
BLACK HAWK SD
57718-8335
US

V. Phone/Fax

Practice location:
  • Phone: 605-431-8595
  • Fax: 605-431-8595
Mailing address:
  • Phone: 605-347-7560
  • Fax: 605-718-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC MH 2025
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC MH 2025
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: