Provider Demographics
NPI:1306646856
Name:DIAMOND, LISA KIM
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:KIM
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BULL HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH GROSVENORDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06255-2004
Mailing Address - Country:US
Mailing Address - Phone:860-212-1936
Mailing Address - Fax:
Practice Address - Street 1:45 BULL HILL RD
Practice Address - Street 2:
Practice Address - City:NORTH GROSVENORDALE
Practice Address - State:CT
Practice Address - Zip Code:06255-2004
Practice Address - Country:US
Practice Address - Phone:860-212-1936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALSWA414220101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor