Provider Demographics
NPI:1457376535
Name:DIAMOND, KENNETH LEE (PHD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 RIVERSIDE DR APT 9F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7280
Mailing Address - Country:US
Mailing Address - Phone:212-472-3137
Mailing Address - Fax:
Practice Address - Street 1:202 RIVERSIDE DR APT 9F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7280
Practice Address - Country:US
Practice Address - Phone:212-472-3137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8158103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0021395OtherGHI
NY01674693Medicaid