Healthcare Provider Details

I. General information

NPI: 1013140151
Provider Name (Legal Business Name): CAROL DIECKMANN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 PLACITA CHUECO
SANTA FE NM
87505-5254
US

IV. Provider business mailing address

1092 EARLY ST SUITE #2
SANTA FE NM
87505-1662
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-8138
  • Fax:
Mailing address:
  • Phone: 505-603-8138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0113631
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0136271
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: