Provider Demographics
NPI:1013159151
Name:DIERKS, DIANE CHAMBERS (MFT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:CHAMBERS
Last Name:DIERKS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:CHAMBERS
Other - Last Name:SHEARER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:PO BOX 1016
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1016
Mailing Address - Country:US
Mailing Address - Phone:404-218-1739
Mailing Address - Fax:404-592-1257
Practice Address - Street 1:400 W CROGAN ST
Practice Address - Street 2:SUITE D
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4736
Practice Address - Country:US
Practice Address - Phone:404-218-1739
Practice Address - Fax:404-592-1257
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001084106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist