Basic Information
| Provider Information | |||||||||
| NPI: | 1801364906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MAINE ST STE A | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441396 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MAINE ST STE A | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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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 | 103TF0000X | Y | Behavioral Health & Social Service Providers | Psychologist | Family |
ID Information
| ID | Type | State | Issuer | Description | 103T00000X | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 103T00000X | 01 | KS | AETNA | OTHER | 103T00000X | 05 | KS | MEDICAID |