Provider Demographics
NPI:1659024958
Name:VAN DIEPEN, KIMBERLY DAWN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:VAN DIEPEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11508 ARUBA DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-1210
Mailing Address - Country:US
Mailing Address - Phone:850-380-8017
Mailing Address - Fax:
Practice Address - Street 1:4400 BAYOU BLVD STE 8
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1908
Practice Address - Country:US
Practice Address - Phone:850-380-8017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health