=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992259535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANE C.KIRK, PSY.D, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2016
-----------------------------------------------------
Last Update Date | 08/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3010 S HARVARD AVE SUITE 110
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74114-6124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-545-5353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1616 E 32ND PL
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74105-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-545-5353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. DIANE C KIRK
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 302-545-5353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1234
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------