Provider Demographics
NPI:1720174816
Name:FOY KUNTZ, DIANE MARIE (MED LP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:FOY KUNTZ
Suffix:
Gender:F
Credentials:MED LP
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:FOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED LP
Mailing Address - Street 1:100 SOUTH FULLER STREET
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379
Mailing Address - Country:US
Mailing Address - Phone:612-644-8824
Mailing Address - Fax:952-447-4907
Practice Address - Street 1:100 SOUTH FULLER STREET
Practice Address - Street 2:SUITE 140
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379
Practice Address - Country:US
Practice Address - Phone:612-644-8824
Practice Address - Fax:952-447-4907
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3144103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN064K7F0OtherBLUE CROSS BLUE SHIELD