Provider Demographics
NPI:1679359855
Name:DIETER, KRISTEN ILONA
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ILONA
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 1:123 NAGYS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-9113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 NAGYS HILL RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:PA
Practice Address - Zip Code:18013-9113
Practice Address - Country:US
Practice Address - Phone:610-462-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW140357104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker