Provider Demographics
NPI:1760701957
Name:VIETZ, MACHELLE DIA (LLMFT)
Entity Type:Individual
Prefix:MRS
First Name:MACHELLE
Middle Name:DIA
Last Name:VIETZ
Suffix:
Gender:F
Credentials:LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68155 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:MI
Mailing Address - Zip Code:49065-9615
Mailing Address - Country:US
Mailing Address - Phone:269-998-4388
Mailing Address - Fax:
Practice Address - Street 1:304 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1012
Practice Address - Country:US
Practice Address - Phone:269-998-4388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006450106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist