MEDICARE: KIMBERLY P. DIAMOND-BERRY PH.D.

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	103TC2200X	Clinical Child & Adolescent Psychologist	0810002868	VA

General Provider Information

NPI Number	:	1952515413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY P. DIAMOND-BERRY PH.D.

Provider Business Mailing Address
First Line	:	1707 BELLE VIEW BLVD
Second Line	:	SUITE C-1
City	:	ALEXANDRIA
State	:	VA
Zip	:	22307-6727
Country	:	US
Telephone Number	:	703-615-6181
Fax Number	:	703-768-6264

Provider Business Practice Location Address
First Line	:	1707 BELLE VIEW BLVD
Second Line	:	SUITE C-1
City	:	ALEXANDRIA
State	:	VA
Zip	:	22307-6727
Country	:	US
Telephone Number	:	703-615-6181
Fax Number	:	703-768-6264

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	07/08/2007

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