Provider Demographics
NPI:1578655957
Name:DIETRICH, CAROL ANNE (PT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANNE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 PARK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4270
Mailing Address - Country:US
Mailing Address - Phone:864-299-1600
Mailing Address - Fax:
Practice Address - Street 1:41 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4270
Practice Address - Country:US
Practice Address - Phone:864-299-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4662225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7228507Medicaid
NC28507OtherBLUE CROSS BLUE SHIELD NC
NC2503992Medicare ID - Type Unspecified