Provider Demographics
NPI:1174185474
Name:DIETERMAN, ISAAC (BA, DP-C)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:DIETERMAN
Suffix:
Gender:M
Credentials:BA, DP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 EASTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6792
Mailing Address - Country:US
Mailing Address - Phone:989-774-1224
Mailing Address - Fax:
Practice Address - Street 1:5816 EASTMAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6792
Practice Address - Country:US
Practice Address - Phone:989-774-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)