Provider Demographics
NPI:1215593306
Name:DIETSCH, MARY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:DIETSCH
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 1:3952 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3005
Mailing Address - Country:US
Mailing Address - Phone:619-297-4145
Mailing Address - Fax:619-297-0237
Practice Address - Street 1:3952 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-3005
Practice Address - Country:US
Practice Address - Phone:619-297-4145
Practice Address - Fax:619-297-0237
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA8380237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist