Provider Demographics
NPI:1043646607
Name:DIERKENS, KAREN SUSAN (PCC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:SUSAN
Last Name:DIERKENS
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4539 COUNTY ROAD 5 2
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:OH
Mailing Address - Zip Code:43515-9658
Mailing Address - Country:US
Mailing Address - Phone:419-460-1860
Mailing Address - Fax:
Practice Address - Street 1:4539 COUNTY ROAD 5 2
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:OH
Practice Address - Zip Code:43515-9658
Practice Address - Country:US
Practice Address - Phone:419-460-1860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-15
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0019326101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional