1821404542 NPI number — MICHELE J DIAMOND M.ED.,M.S./CAS, LPES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821404542 NPI number — MICHELE J DIAMOND M.ED.,M.S./CAS, LPES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAMOND
Provider First Name:
MICHELE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED.,M.S./CAS, LPES
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821404542
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 CLAY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWLEYS ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29585-9998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-400-8707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5187 HORRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRELLS INLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29576-5242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-400-8707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TS0200X , with the licence number:  4606 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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