Provider Demographics
NPI:1164709747
Name:DIONYSUS, KIMBERLY E (PSYD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:DIONYSUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:E
Other - Last Name:DIOUNYSUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2030 S NATIONAL AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2238
Mailing Address - Country:US
Mailing Address - Phone:417-820-9590
Mailing Address - Fax:
Practice Address - Street 1:2030 S NATIONAL AVE STE 105
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2238
Practice Address - Country:US
Practice Address - Phone:417-820-9590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009108103G00000X
MO2011037843103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200437390AMedicaid
MP1164709747Medicaid
KS200750120AMedicaid
MO135740003Medicare PIN
KS200750120AMedicaid