Provider Demographics
NPI:1568675031
Name:DIEBOLT, AMY KATHERINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:KATHERINE
Last Name:DIEBOLT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DIEBOLT
Other - Last Name:KRISTOFITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2888 N LONGHORN DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85749-9754
Mailing Address - Country:US
Mailing Address - Phone:520-991-7996
Mailing Address - Fax:
Practice Address - Street 1:2888 N LONGHORN DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85749-9754
Practice Address - Country:US
Practice Address - Phone:520-991-7996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3137103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ566929Medicaid