Basic Information
| Provider Information | |||||||||
| NPI: | 1245451806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOUPE | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. ED., L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 E HIGHWAY 28 | ||||||||
| Address2: | |||||||||
| City: | OWENSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650661588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734372959 | ||||||||
| FaxNumber: | 5734372974 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608908186 | ||||||||
| FaxNumber: | 8163183109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2001003594 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 497265306 | 05 | MO | MEDICAID |