Provider Demographics
NPI:1659740389
Name:DIETZ, COURTNIE (PTA)
Entity Type:Individual
Prefix:
First Name:COURTNIE
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW ATHENS
Mailing Address - State:IL
Mailing Address - Zip Code:62264-1108
Mailing Address - Country:US
Mailing Address - Phone:618-980-5837
Mailing Address - Fax:
Practice Address - Street 1:13138 IL-13
Practice Address - Street 2:
Practice Address - City:COULTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62237-1218
Practice Address - Country:US
Practice Address - Phone:618-758-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant