Provider Demographics
NPI: | 1548212145 |
---|---|
Name: | DIMOND, RICHARD E (PHD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RICHARD |
Middle Name: | E |
Last Name: | DIMOND |
Suffix: | |
Gender: | M |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2921 GREENBRIAR DR |
Mailing Address - Street 2: | SUITE B-1 |
Mailing Address - City: | SPRINGFIELD |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 62704-6425 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 217-546-3118 |
Mailing Address - Fax: | 217-546-3184 |
Practice Address - Street 1: | 2921 GREENBRIAR DR |
Practice Address - Street 2: | SUITE B-1 |
Practice Address - City: | SPRINGFIELD |
Practice Address - State: | IL |
Practice Address - Zip Code: | 62704-6425 |
Practice Address - Country: | US |
Practice Address - Phone: | 217-546-3118 |
Practice Address - Fax: | 217-546-3184 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-16 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 7364205 | Other | AETNA |
IL | 013265 (MHS) | Other | VALUE OPTIONS |
IL | 064593 | Other | HEALTH ALLIANCE |
IL | 137075 | Other | HEALTH LINK |
IL | 013265 (MHS) | Other | VALUE OPTIONS |