Provider Demographics
NPI:1326101080
Name:DIEDERICH, HEATHER LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LYNN
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 DORSET ST
Mailing Address - Street 2:STE 3
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6236
Mailing Address - Country:US
Mailing Address - Phone:802-864-4959
Mailing Address - Fax:
Practice Address - Street 1:368 DORSET ST
Practice Address - Street 2:STE 3
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6236
Practice Address - Country:US
Practice Address - Phone:802-864-4959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006-0000998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT006-0000998OtherLICENSCE
VTOVN1626Medicaid
VT030360008OtherEIN