Provider Demographics
NPI:1194948661
Name:INNES, DIANE LYNETTE (MA, LLP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:LYNETTE
Last Name:INNES
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11217 SOUTHWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4466
Mailing Address - Country:US
Mailing Address - Phone:734-927-4645
Mailing Address - Fax:
Practice Address - Street 1:26300 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2019
Practice Address - Country:US
Practice Address - Phone:313-388-4630
Practice Address - Fax:313-388-4672
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010778103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist