=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073648143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE SPADE MA., LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 02/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 908 2ND ST
-----------------------------------------------------
City | MENOMINEE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49858-3245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-864-9830
-----------------------------------------------------
Fax | 906-864-9831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 908 2ND ST
-----------------------------------------------------
City | MENOMINEE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49858-3245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-864-9830
-----------------------------------------------------
Fax | 906-864-9831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6401010032
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------