Provider Demographics
NPI:1568087765
Name:DIETZ, MEGAN L (LCSW-R)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:L
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-4380
Mailing Address - Country:US
Mailing Address - Phone:315-569-2712
Mailing Address - Fax:
Practice Address - Street 1:320 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-4380
Practice Address - Country:US
Practice Address - Phone:315-569-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0797061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical