Healthcare Provider Details

I. General information

NPI: 1801364906
Provider Name (Legal Business Name): MISS KATHLEEN I DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAINE ST STE A
LAWRENCE KS
66044-1396
US

IV. Provider business mailing address

200 MAINE ST STE A
LAWRENCE KS
66044-1396
US

V. Phone/Fax

Practice location:
  • Phone: 785-843-9192
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: