=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144432246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY DIACHENKO FOSTER M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2554 LEWISVILLE CLEMMONS RD STE 303
-----------------------------------------------------
City | CLEMMONS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27012-8749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-849-7890
-----------------------------------------------------
Fax | 336-223-5060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 723
-----------------------------------------------------
City | YADKINVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27055-0723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-223-5060
-----------------------------------------------------
Fax | 855-726-7734
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3555
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 3555
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 3555
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------