Provider Demographics
NPI:1194015388
Name:DIETHERT, CHRISTOPHER (LMT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:DIETHERT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 N ARLINGTON HEIGHTS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-4830
Mailing Address - Country:US
Mailing Address - Phone:224-279-8330
Mailing Address - Fax:
Practice Address - Street 1:1430 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-4830
Practice Address - Country:US
Practice Address - Phone:224-279-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist