Provider Demographics
NPI:1609435312
Name:DIETRICH, ELLI MARSHALL (LMSW)
Entity Type:Individual
Prefix:
First Name:ELLI
Middle Name:MARSHALL
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 BUSINESS PKWY S STE A
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-3004
Mailing Address - Country:US
Mailing Address - Phone:667-600-2850
Mailing Address - Fax:
Practice Address - Street 1:1129 BUSINESS PKWY S STE A
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-3004
Practice Address - Country:US
Practice Address - Phone:667-600-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22772104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker