Provider Demographics
NPI:1891856860
Name:BISHOP-DIAZ, KELLY L (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:BISHOP-DIAZ
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 1:2285 STAR S AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3478
Mailing Address - Country:US
Mailing Address - Phone:701-330-8210
Mailing Address - Fax:
Practice Address - Street 1:2285 STAR S AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3478
Practice Address - Country:US
Practice Address - Phone:701-330-8210
Practice Address - Fax:701-330-8210
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND513103TC0700X
TN2616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4107555OtherBCBS TN
TN3981717Medicare ID - Type UnspecifiedMEDICARE