Healthcare Provider Details

I. General information

NPI: 1114229275
Provider Name (Legal Business Name): INGRID DIEDEREN PHD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 ASHELAND AVE SUITE D
ASHEVILLE NC
28801-4005
US

IV. Provider business mailing address

172 ASHELAND AVE SUITE D
ASHEVILLE NC
28801-0172
US

V. Phone/Fax

Practice location:
  • Phone: 828-253-1445
  • Fax: 828-253-1456
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1376
License Number StateNC

VIII. Authorized Official

Name: DR. INGRID MARY DIEDEREN
Title or Position: PRESIDENT
Credential: PHD
Phone: 828-253-1445