Provider Demographics
NPI:1932267887
Name:DIEDEREN, INGRID MARY (PH D)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:MARY
Last Name:DIEDEREN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 ASHELAND AVENUE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801
Mailing Address - Country:US
Mailing Address - Phone:828-253-1445
Mailing Address - Fax:828-253-1456
Practice Address - Street 1:172 ASHELAND AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801
Practice Address - Country:US
Practice Address - Phone:828-253-1445
Practice Address - Fax:828-253-1456
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1376103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0324HOtherBCBS
2817035AMedicare ID - Type Unspecified