Provider Demographics
NPI:1225185366
Name:DIECKMAN, MARI DOLORES (PT)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:DOLORES
Last Name:DIECKMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E ELM AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3258
Mailing Address - Country:US
Mailing Address - Phone:928-213-9730
Mailing Address - Fax:928-213-9732
Practice Address - Street 1:125 E ELM AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3258
Practice Address - Country:US
Practice Address - Phone:928-213-9730
Practice Address - Fax:928-213-9732
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2093225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP93780Medicare UPIN
AZ75739Medicare ID - Type Unspecified