Provider Demographics
NPI:1174294847
Name:DIETZ, TAYLOR ANNE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANNE
Last Name:DIETZ
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 1:1454 SUNSET CLIFFS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3848
Mailing Address - Country:US
Mailing Address - Phone:916-812-7978
Mailing Address - Fax:
Practice Address - Street 1:7592 METROPOLITAN DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4428
Practice Address - Country:US
Practice Address - Phone:916-812-7978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician