Provider Demographics
NPI:1033350723
Name:DIETERICH, ROSALIND MACKRAZ (MSW)
Entity Type:Individual
Prefix:MRS
First Name:ROSALIND
Middle Name:MACKRAZ
Last Name:DIETERICH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 BRIAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9400
Mailing Address - Country:US
Mailing Address - Phone:734-646-7297
Mailing Address - Fax:734-661-0116
Practice Address - Street 1:2900 PACKARD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2060
Practice Address - Country:US
Practice Address - Phone:734-528-9703
Practice Address - Fax:734-572-8866
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010909901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical