Provider Demographics
NPI:1326163486
Name:DIETZEL, CHARLES EDWARD JR
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:DIETZEL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:EDWARD
Other - Last Name:DIETZEL
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:36 HANDCOC AVE.
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:ME
Mailing Address - Zip Code:04041
Mailing Address - Country:US
Mailing Address - Phone:207-625-8947
Mailing Address - Fax:
Practice Address - Street 1:36 HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:ME
Practice Address - Zip Code:04041
Practice Address - Country:US
Practice Address - Phone:207-625-8947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional