Provider Demographics
NPI:1356311344
Name:DIETZ, BLANCHE G (MSW)
Entity Type:Individual
Prefix:MS
First Name:BLANCHE
Middle Name:G
Last Name:DIETZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HEMENWAY RD
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-2636
Mailing Address - Country:US
Mailing Address - Phone:508-380-2499
Mailing Address - Fax:508-788-0344
Practice Address - Street 1:190 HEMENWAY RD
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-2636
Practice Address - Country:US
Practice Address - Phone:508-380-2499
Practice Address - Fax:508-788-0344
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10188231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP05262OtherBLUE CROSS BLUE SHIELD
052568000OtherMAGELLAN
R42849Medicare UPIN