Provider Demographics
NPI:1598906216
Name:DIECKMANN, BRIAN VINCENT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:VINCENT
Last Name:DIECKMANN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13650 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9800
Mailing Address - Country:US
Mailing Address - Phone:219-677-2462
Mailing Address - Fax:
Practice Address - Street 1:13650 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-9800
Practice Address - Country:US
Practice Address - Phone:219-677-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042237A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical