Provider Demographics
NPI:1275645640
Name:DIETZ, CHRISTINE (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1102
Mailing Address - Country:US
Mailing Address - Phone:716-859-4726
Mailing Address - Fax:716-859-4818
Practice Address - Street 1:1010 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1102
Practice Address - Country:US
Practice Address - Phone:716-859-4726
Practice Address - Fax:716-859-4818
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC6618101YM0800X, 1041C0700X
NY032904-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME415040000Medicaid
ME415040099Medicaid
MEME1269Medicare ID - Type Unspecified