Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 4074924 | AZ |
NPI | 1003067919 |
---|---|
Provider Name | Marcia C Diederich |
First Address | Phoenix, AZ 85083-4335 |
Second Address | Phoenix, AZ 85083-4335 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/10/2008 |
Last Update Date | 09/10/2008 |