Provider Demographics
NPI:1346716081
Name:DIETRICHSON, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:DIETRICHSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 N MOPAC EXPY STE 402
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8500 N MOPAC EXPY STE 402
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8347
Practice Address - Country:US
Practice Address - Phone:512-902-3282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-20
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX666921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical