Provider Demographics
NPI:1497784607
Name:DIEDE, AMY (LAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DIEDE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ROCHELLE
Other - Last Name:BESHEARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:4253 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4593
Mailing Address - Country:US
Mailing Address - Phone:479-521-5731
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:10301 MAYO DR
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923-1660
Practice Address - Country:US
Practice Address - Phone:479-494-5760
Practice Address - Fax:479-484-8142
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0210072101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor