Provider Demographics
NPI:1407228893
Name:DIETRICH, STEPHANIE R (LCSW-S)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:LCSW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 N LOGAN ST
Mailing Address - Street 2:STE 100
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77590-5172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16852 ROYAL CREST DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2529
Practice Address - Country:US
Practice Address - Phone:281-305-8552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX559191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$OtherSOCIAL SECURITY