=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245567429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE-ANNE DIEHL PSY.D., R.N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2009
-----------------------------------------------------
Last Update Date | 06/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 LITHIA PINECREST RD
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-5307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-957-2765
-----------------------------------------------------
Fax | 813-502-6144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 LITHIA PINECREST RD
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-5307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-957-2765
-----------------------------------------------------
Fax | 813-502-6144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 8005
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 9197701
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------