Provider Demographics
NPI:1366043481
Name:DIETRICK, HALEY ALANE (OTR/L)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:ALANE
Last Name:DIETRICK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10418 JUBILEE RD
Mailing Address - Street 2:
Mailing Address - City:LA PORTE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50651-2059
Mailing Address - Country:US
Mailing Address - Phone:319-240-2868
Mailing Address - Fax:
Practice Address - Street 1:217 E BREMER AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-3435
Practice Address - Country:US
Practice Address - Phone:319-352-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099828225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist