MEDICARE: KIMBERLY E DIONYSUS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	071009108	IL
2	103G00000X	Clinical Neuropsychologist	2011037843	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164709747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY E DIONYSUS PSYD

Provider Business Mailing Address
First Line	:	2030 S NATIONAL AVE STE 105
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2238
Country	:	US
Telephone Number	:	417-820-9590
Fax Number	:

Provider Business Practice Location Address
First Line	:	2030 S NATIONAL AVE STE 105
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2238
Country	:	US
Telephone Number	:	417-820-9590
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2011
Last Update Date	:	07/09/2020

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Directions to “ KIMBERLY E DIONYSUS PSYD” Practice Location

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