Provider Demographics
NPI:1477646727
Name:DIEDRICH, ELLEN MARY (LPC)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:MARY
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 S 68TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-3479
Mailing Address - Country:US
Mailing Address - Phone:414-585-9881
Mailing Address - Fax:414-585-9867
Practice Address - Street 1:4402 S 68TH ST STE 102
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-3479
Practice Address - Country:US
Practice Address - Phone:414-585-9881
Practice Address - Fax:414-585-9867
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1927101YA0400X
WI33-036101YM0800X
WI2532-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20-2887407OtherTAX ID #
WI39686300Medicaid