Healthcare Provider Details

I. General information

NPI: 1164709747
Provider Name (Legal Business Name): KIMBERLY E DIONYSUS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY E. DIOUNYSUS

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 S NATIONAL AVE STE 105
SPRINGFIELD MO
65804-2238
US

IV. Provider business mailing address

2030 S NATIONAL AVE STE 105
SPRINGFIELD MO
65804-2238
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-9590
  • Fax:
Mailing address:
  • Phone: 417-820-9590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071009108
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2011037843
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: