Provider Demographics
NPI:1619481603
Name:DIETER, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:DIETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 BLOSSOM RD STE 315
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1825
Mailing Address - Country:US
Mailing Address - Phone:585-210-0279
Mailing Address - Fax:
Practice Address - Street 1:595 BLOSSOM RD STE 315
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1825
Practice Address - Country:US
Practice Address - Phone:585-210-0279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007304101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty