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General NPI Number Information
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NPI Number | 1790176576
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Entity Type | Individual
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Provider Name | DIANE J GORES LPC
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Gender | Female
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Dates
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Enumeration Date | 02/14/2015
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Last Update Date | 05/23/2019
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Provider Practice Location Address
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Address Line | 127 LAKE HOUSE RD
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City | POOLER
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State | GA
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Zip | 31322-9710
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Country | US
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Telephone | 912-713-4684
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Fax |
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Provider Business Mailing Address
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Address Line | 127 LAKE HOUSE RD
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City | POOLER
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State | GA
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Zip | 31322-9710
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Country | US
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Telephone | 912-713-4684
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC007991
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License Number State | GA
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