Provider Demographics
NPI:1376672667
Name:DIETZEN, MARY ANN (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:DIETZEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 N. DIVISION SUITE 505
Mailing Address - Street 2:
Mailing Address - City:SPOKANE,
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1613
Mailing Address - Country:US
Mailing Address - Phone:509-487-9131
Mailing Address - Fax:509-482-9022
Practice Address - Street 1:4407 N DIVISION ST STE 505
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1613
Practice Address - Country:US
Practice Address - Phone:509-487-9131
Practice Address - Fax:509-482-9022
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1559103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling