Provider Demographics
NPI:1396028528
Name:RAK-DIETZ, COLIN M (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:M
Last Name:RAK-DIETZ
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:COLIN
Other - Middle Name:M
Other - Last Name:DIETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1905 S NEW MARKET ST STE 260
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7424
Mailing Address - Country:US
Mailing Address - Phone:317-564-9797
Mailing Address - Fax:877-401-3034
Practice Address - Street 1:1905 S NEW MARKET ST STE 260
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7424
Practice Address - Country:US
Practice Address - Phone:317-564-9797
Practice Address - Fax:877-401-3034
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00000000A103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical