Provider Demographics
NPI:1376039818
Name:DIECK, MARSDEN CLAIRE
Entity Type:Individual
Prefix:
First Name:MARSDEN
Middle Name:CLAIRE
Last Name:DIECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 INDUSTRIAL DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0700
Mailing Address - Country:US
Mailing Address - Phone:507-322-7751
Mailing Address - Fax:
Practice Address - Street 1:5501 FELTL RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-3944
Practice Address - Country:US
Practice Address - Phone:952-746-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MNBACB347083103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician