Provider Demographics
NPI:1497964779
Name:DIKEMAN, VIRGINIA L (MA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:L
Last Name:DIKEMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 WOODLAND WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2713
Mailing Address - Country:US
Mailing Address - Phone:570-586-1467
Mailing Address - Fax:
Practice Address - Street 1:1023 WOODLAND WAY
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-2713
Practice Address - Country:US
Practice Address - Phone:570-586-1467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS6498L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist