=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013140151
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL DIECKMANN LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2009
-----------------------------------------------------
Last Update Date | 06/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2702 PLACITA CHUECO
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-603-8138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1092 EARLY ST SUITE #2
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-1662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-603-8138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0113631
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0136271
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------