Provider Demographics
NPI:1013140151
Name:DIECKMANN, CAROL (LPCC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DIECKMANN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1092 EARLY ST
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-1662
Mailing Address - Country:US
Mailing Address - Phone:505-603-8138
Mailing Address - Fax:
Practice Address - Street 1:2702 PLACITA CHUECO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5254
Practice Address - Country:US
Practice Address - Phone:505-603-8138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0113631101YM0800X
NM0136271101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health