=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659024958
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. KIMBERLY DAWN VAN DIEPEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2022
-----------------------------------------------------
Last Update Date | 01/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 BAYOU BLVD STE 8
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-380-8017
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11508 ARUBA DR
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32506-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-380-8017
-----------------------------------------------------
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 | 20771
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------