Healthcare Provider Details

I. General information

NPI: 1497131544
Provider Name (Legal Business Name): DIANE M KEDZIERSKI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10768 SW 67TH TER
OCALA FL
34476-4761
US

IV. Provider business mailing address

10768 SW 67TH TER
OCALA FL
34476-4761
US

V. Phone/Fax

Practice location:
  • Phone: 352-300-0321
  • Fax: 352-509-4257
Mailing address:
  • Phone: 352-300-0321
  • Fax: 352-509-4257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberB1-0011401
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY9729
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: