Provider Demographics
NPI:1124291679
Name:DIECKHOFF, ROBERT J
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:DIECKHOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:J
Other - Last Name:DIECKHOFF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:216 KEVIN CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-9781
Mailing Address - Country:US
Mailing Address - Phone:417-466-0530
Mailing Address - Fax:417-667-2410
Practice Address - Street 1:216 KEVIN CIR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-9781
Practice Address - Country:US
Practice Address - Phone:417-466-0530
Practice Address - Fax:417-667-2410
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0038221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000078773OtherMEDICARE