Provider Demographics
NPI:1396194056
Name:DIETRICH, CRYSTAL ROSE (CMT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:UPSALA
Mailing Address - State:MN
Mailing Address - Zip Code:56384-0152
Mailing Address - Country:US
Mailing Address - Phone:320-733-0153
Mailing Address - Fax:
Practice Address - Street 1:204 BORGSTROM ST
Practice Address - Street 2:
Practice Address - City:UPSALA
Practice Address - State:MN
Practice Address - Zip Code:56384-4501
Practice Address - Country:US
Practice Address - Phone:320-733-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist