MEDICARE: KIM DIEFENTHALER TAYLER MA, LPC, LCDC, CCTP

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	101YP2500X	Professional Counselor	82496	TX

General Provider Information

NPI Number	:	1689313769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM DIEFENTHALER TAYLER MA, LPC, LCDC, CCTP

Provider Business Mailing Address
First Line	:	11706 BIRCHBARK TRL
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78750-1341
Country	:	US
Telephone Number	:	949-680-6555
Fax Number	:

Provider Business Practice Location Address
First Line	:	11706 BIRCHBARK TRL
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78750-1341
Country	:	US
Telephone Number	:	949-680-6555
Fax Number	:

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

Provider Enumeration Date	:	05/27/2022
Last Update Date	:	05/27/2022

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