=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154823110
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALLIE DIAMONSTEIN MS, LCGC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2018
-----------------------------------------------------
Last Update Date | 05/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5323 HARRY HINES BLVD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-648-0860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6363 FOREST PARK RD STE BLB.306
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-5479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-645-2563
-----------------------------------------------------
Fax | 214-645-2562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0203X
-----------------------------------------------------
Taxonomy Name | Clinical Molecular Genetics Physician
-----------------------------------------------------
License Number | 0139000042
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 170300000X
-----------------------------------------------------
Taxonomy Name | Genetic Counselor (M.S.)
-----------------------------------------------------
License Number | 0139000042
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------