Provider Demographics
NPI:1376819458
Name:DIETZ, KATIE M (LMP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N SHETLAND CT
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5447
Mailing Address - Country:US
Mailing Address - Phone:208-215-8140
Mailing Address - Fax:
Practice Address - Street 1:605 N SHETLAND CT
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5447
Practice Address - Country:US
Practice Address - Phone:208-215-8140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60221323172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist