Provider Demographics
NPI:1376327213
Name:DIETTERICK, KYLEIGH
Entity Type:Individual
Prefix:
First Name:KYLEIGH
Middle Name:
Last Name:DIETTERICK
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 1:110 BUE JAY RD
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17846
Mailing Address - Country:US
Mailing Address - Phone:570-380-0941
Mailing Address - Fax:
Practice Address - Street 1:759 SUSQUEHANNA TRL
Practice Address - Street 2:
Practice Address - City:WATSONTOWN
Practice Address - State:PA
Practice Address - Zip Code:17777-8109
Practice Address - Country:US
Practice Address - Phone:570-428-9504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)