=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598019648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY ANN DIENES PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2012
-----------------------------------------------------
Last Update Date | 10/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 S DEARBORN ST SUITE 702
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-504-4363
-----------------------------------------------------
Fax | 312-279-7576
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 431 S DEARBORN ST SUITE 702
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-504-4363
-----------------------------------------------------
Fax | 312-279-7576
-----------------------------------------------------
=====================================================
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 | 071007918
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------