Provider Demographics
NPI:1235202656
Name:DIETZ, CARLY RAE (MA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:RAE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:RAE
Other - Last Name:BETTGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1517 GOLDEN GATE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-4514
Mailing Address - Country:US
Mailing Address - Phone:415-572-1763
Mailing Address - Fax:
Practice Address - Street 1:2513 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3556
Practice Address - Country:US
Practice Address - Phone:415-264-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor