Provider Demographics
NPI:1295396695
Name:DIETZ, TAMI GRAVEN (LCSA)
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:GRAVEN
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9719 ARAGORN LN NW
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6998
Mailing Address - Country:US
Mailing Address - Phone:704-807-7545
Mailing Address - Fax:
Practice Address - Street 1:9719 ARAGORN LN NW
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6998
Practice Address - Country:US
Practice Address - Phone:704-807-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC007510104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker