Basic Information
| Provider Information | |||||||||
| NPI: | 1629432166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEADAPOHL | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12075 MONSBROOK DR | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483121342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862431029 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22708 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480801823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864452210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
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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 | 101YM0800X | 6801097007 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.