MEDICARE: DIANE MENKE PENCE LMHC, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	39002125	IN
2	101YM0800X	Mental Health Counselor	LPC.0012588	CO
3	101YM0800X	Mental Health Counselor	2016031492	MO

General Provider Information

NPI Number	:	1588993992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MENKE PENCE LMHC, LPC

Provider Business Mailing Address
First Line	:	1337 PINE BLUFF DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63304-8785
Country	:	US
Telephone Number	:	217-549-9292
Fax Number	:

Provider Business Practice Location Address
First Line	:	2536 S OLD HIGHWAY 94
Second Line	:	SUITE 234
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-5612
Country	:	US
Telephone Number	:	636-896-5842
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2009
Last Update Date	:	10/14/2016

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