Provider Demographics
NPI:1871368183
Name:VIA, DIAMOND MACKENZIE
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:MACKENZIE
Last Name:VIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W SHANNON LN APT 12
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-4919
Mailing Address - Country:US
Mailing Address - Phone:502-773-1953
Mailing Address - Fax:
Practice Address - Street 1:1230 LIBERTY BANK LN STE 230
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5756
Practice Address - Country:US
Practice Address - Phone:502-792-9269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-23-284843106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician