Provider Demographics
NPI:1003067919
Name:DIEDERICH, MARCIA C
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:C
Last Name:DIEDERICH
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 1:25250 N 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-4335
Mailing Address - Country:US
Mailing Address - Phone:623-445-7100
Mailing Address - Fax:623-445-7180
Practice Address - Street 1:25250 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-4335
Practice Address - Country:US
Practice Address - Phone:623-445-7100
Practice Address - Fax:623-445-7180
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4074924103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool