Provider Demographics
NPI:1235400599
Name:DIETERICH, SHAUN (LMHC)
Entity Type:Individual
Prefix:MR
First Name:SHAUN
Middle Name:
Last Name:DIETERICH
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S PLAISTED AVE
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-2755
Mailing Address - Country:US
Mailing Address - Phone:631-780-5828
Mailing Address - Fax:
Practice Address - Street 1:121 S PLAISTED AVE
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2755
Practice Address - Country:US
Practice Address - Phone:631-780-5828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004586101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health