Provider Demographics
NPI:1598019648
Name:DIENES, KIMBERLY ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:DIENES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 S DEARBORN ST
Mailing Address - Street 2:SUITE 702
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1100
Mailing Address - Country:US
Mailing Address - Phone:312-504-4363
Mailing Address - Fax:312-279-7576
Practice Address - Street 1:431 S DEARBORN ST
Practice Address - Street 2:SUITE 702
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1100
Practice Address - Country:US
Practice Address - Phone:312-504-4363
Practice Address - Fax:312-279-7576
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-27
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071007918OtherCLINICAL PSYCHOLOGIST LICENSE NUMBER