=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023339967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANE MENKE PENCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2010
-----------------------------------------------------
Last Update Date | 06/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 N COLLEGE AVE STE 613
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47404-3950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-333-3440
-----------------------------------------------------
Fax | 812-333-3444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1522 N LIMESTONE DR
-----------------------------------------------------
City | ELLETTSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47429-9363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-876-6322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIANE MENKE PENCE
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 812-876-6322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 39002125A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------