Provider Demographics
NPI:1508310384
Name:DIEDERICH, AMBER (CADC I, CRM)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:CADC I, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 I AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2043
Mailing Address - Country:US
Mailing Address - Phone:541-962-0162
Mailing Address - Fax:
Practice Address - Street 1:1501 6TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2419
Practice Address - Country:US
Practice Address - Phone:541-962-0162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-CRM-141175T00000X
OR17-06-28101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist