Basic Information
| Provider Information | |||||||||
| NPI: | 1649305038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIELEMAN | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA LLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENEKE | ||||||||
| OtherFirstName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2615 STADIUM DRIVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490081654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693431651 | ||||||||
| FaxNumber: | 2693827078 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 STADIUM DRIVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490081654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693431651 | ||||||||
| FaxNumber: | 2693827078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301009213 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.