Provider Demographics
NPI:1598061780
Name:KIRK, DIANE CONSTANCE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:CONSTANCE
Last Name:KIRK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:CS
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:1616 E 32ND PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2117
Mailing Address - Country:US
Mailing Address - Phone:918-992-7006
Mailing Address - Fax:918-749-1841
Practice Address - Street 1:3010 S HARVARD AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6124
Practice Address - Country:US
Practice Address - Phone:302-948-6030
Practice Address - Fax:918-749-1841
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000315103TC0700X
OK1234103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200594670AMedicaid