Basic Information
| Provider Information | |||||||||
| NPI: | 1902324023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIEKHOFF | ||||||||
| FirstName: | DEANA | ||||||||
| MiddleName: | DANILOVA | ||||||||
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| Credential: | LPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3631 NEW LONDON RD | ||||||||
| Address2: | |||||||||
| City: | HENRIETTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763657036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405671082 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1101 SCOTT AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763014671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9407619700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 37037 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 08091980 | 01 | TX | NPI | OTHER |