Provider Demographics
NPI:1114229275
Name:INGRID DIEDEREN PHD PA
Entity type:Organization
Organization Name:INGRID DIEDEREN PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:DIEDEREN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:828-253-1445
Mailing Address - Street 1:172 ASHELAND AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-0172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:172 ASHELAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4005
Practice Address - Country:US
Practice Address - Phone:828-253-1445
Practice Address - Fax:828-253-1456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1376261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health