Provider Demographics
NPI:1619521465
Name:DIAH, KIMBERLY CHANTELLE (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CHANTELLE
Last Name:DIAH
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2671
Mailing Address - Fax:319-384-9552
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2671
Practice Address - Fax:319-384-9552
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA114355103T00000X, 103TC0700X, 103G00000X
KS2925103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical