Provider Demographics
NPI:1538286414
Name:DIETRICH, KENDA J (LPC, LPA)
Entity Type:Individual
Prefix:
First Name:KENDA
Middle Name:J
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:LPC, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 OLD BROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78417-9765
Mailing Address - Country:US
Mailing Address - Phone:361-906-0166
Mailing Address - Fax:361-994-7550
Practice Address - Street 1:5440 OLD BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78417-9765
Practice Address - Country:US
Practice Address - Phone:361-906-0166
Practice Address - Fax:361-994-7550
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15820101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0960528-02Medicaid