Provider Demographics
NPI:1144432246
Name:FOSTER, AMY DIACHENKO (MA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:DIACHENKO
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-0723
Mailing Address - Country:US
Mailing Address - Phone:336-223-5060
Mailing Address - Fax:855-726-7734
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 303
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8749
Practice Address - Country:US
Practice Address - Phone:336-849-7890
Practice Address - Fax:336-223-5060
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NC3555103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107576Medicaid