Provider Demographics
NPI:1083285035
Name:DIETZ, ZACHARY LOGAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:LOGAN
Last Name:DIETZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-3443
Mailing Address - Country:US
Mailing Address - Phone:843-814-9129
Mailing Address - Fax:
Practice Address - Street 1:325 FOLLY RD STE 107
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2507
Practice Address - Country:US
Practice Address - Phone:843-762-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist