Provider Demographics
NPI:1235452582
Name:DIEDRICK, SUSAN M
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:DIEDRICK
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 1:845 S MAIN ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6174
Mailing Address - Country:US
Mailing Address - Phone:920-322-0447
Mailing Address - Fax:920-322-1362
Practice Address - Street 1:845 S MAIN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6174
Practice Address - Country:US
Practice Address - Phone:920-322-0447
Practice Address - Fax:920-322-1362
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist