Provider Demographics
NPI:1689722985
Name:HIATT, DIETRAH CHAPMAN (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:DIETRAH
Middle Name:CHAPMAN
Last Name:HIATT
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 CHOWEN AVE S APT 326
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4534
Mailing Address - Country:US
Mailing Address - Phone:612-362-0104
Mailing Address - Fax:
Practice Address - Street 1:1919 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3453
Practice Address - Country:US
Practice Address - Phone:651-266-7932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN139501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN443242800Medicaid