Provider Demographics
NPI:1972080661
Name:PETRY, DIANE LYNN (MA, LMHCA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:PETRY
Suffix:
Gender:F
Credentials:MA, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5784 N 600 E
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-9036
Mailing Address - Country:US
Mailing Address - Phone:317-409-1035
Mailing Address - Fax:
Practice Address - Street 1:9840 WESTPOINT DR STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3368
Practice Address - Country:US
Practice Address - Phone:317-585-1060
Practice Address - Fax:317-585-9811
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000447A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health