Provider Demographics
NPI:1992259535
Name:DIANE C.KIRK, PSY.D, PLLC
Entity type:Organization
Organization Name:DIANE C.KIRK, PSY.D, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:302-545-5353
Mailing Address - Street 1:1616 E 32ND PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2117
Mailing Address - Country:US
Mailing Address - Phone:302-545-5353
Mailing Address - Fax:
Practice Address - Street 1:3010 S HARVARD AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6124
Practice Address - Country:US
Practice Address - Phone:302-545-5353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1234103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200594670AMedicaid