Provider Demographics
NPI:1346887700
Name:DIETZ, MELINDA SUE (LAT, AT, ATC)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:SUE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LAT, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14717 HAMPDEN ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6101
Mailing Address - Country:US
Mailing Address - Phone:734-664-0077
Mailing Address - Fax:
Practice Address - Street 1:14717 HAMPDEN ST
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6101
Practice Address - Country:US
Practice Address - Phone:734-664-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI893614894OtherBLUE CROSS BLUE SHIELD