Provider Demographics
NPI:1447559919
Name:DIEM, ANN KILGORE (LMFT)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:KILGORE
Last Name:DIEM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:CAROL
Other - Last Name:KILGORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:14801 CHESDIN GREEN WAY
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-3278
Mailing Address - Country:US
Mailing Address - Phone:714-322-9761
Mailing Address - Fax:
Practice Address - Street 1:14801 CHESDIN GREEN WAY
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23838-3278
Practice Address - Country:US
Practice Address - Phone:714-322-9761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001358106H00000X
CAMFC 34408106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA601048159Medicaid