Provider Demographics
NPI:1003221383
Name:DIECKMAN, CHRISTIANE
Entity Type:Individual
Prefix:
First Name:CHRISTIANE
Middle Name:
Last Name:DIECKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4168
Mailing Address - Country:US
Mailing Address - Phone:321-205-4182
Mailing Address - Fax:
Practice Address - Street 1:7550 FUTURES DR STE 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9096
Practice Address - Country:US
Practice Address - Phone:407-730-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIHM12064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health