Provider Demographics
NPI:1164793055
Name:DIEBOLT, LYDIA KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:KATHLEEN
Last Name:DIEBOLT
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 1:1229 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-3233
Mailing Address - Country:US
Mailing Address - Phone:785-843-2039
Mailing Address - Fax:785-749-5064
Practice Address - Street 1:204 W 13TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-3404
Practice Address - Country:US
Practice Address - Phone:785-843-2039
Practice Address - Fax:785-749-5064
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7643104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker