Provider Demographics
NPI:1639514318
Name:DIEDRICH, MARY ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DIEDRICH
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4530 E MUIRWOOD DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7639
Mailing Address - Country:US
Mailing Address - Phone:480-961-2365
Mailing Address - Fax:
Practice Address - Street 1:4530 E MUIRWOOD DR
Practice Address - Street 2:SUITE 111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7639
Practice Address - Country:US
Practice Address - Phone:480-961-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist