Healthcare Provider Details

I. General information

NPI: 1164458931
Provider Name (Legal Business Name): DIAKONOS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 LITTLE BLUE PKWY SUITE 360
INDEPENDENCE MO
64057-8312
US

IV. Provider business mailing address

4200 LITTLE BLUE PKWY SUITE 360
INDEPENDENCE MO
64057-8312
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-9240
  • Fax: 816-373-9243
Mailing address:
  • Phone: 816-373-9240
  • Fax: 816-373-9243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0007690
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0007690
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0007690
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0007690
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0007690
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0007690
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0007690
License Number StateMO
# 8
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0007690
License Number StateMO

VIII. Authorized Official

Name: MR. BRIAN ANDREW FIDLER
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 816-373-9240