Provider Demographics
NPI:1790902625
Name:DITTRICH, CONNIE L (MA, LP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:DITTRICH
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:MRS
Other - First Name:CONSTANCE
Other - Middle Name:L
Other - Last Name:DITTRICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6542 REGENCY LANE
Mailing Address - Street 2:#209
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344
Mailing Address - Country:US
Mailing Address - Phone:952-903-9250
Mailing Address - Fax:
Practice Address - Street 1:6542 REGENCY LN
Practice Address - Street 2:#209
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7847
Practice Address - Country:US
Practice Address - Phone:952-903-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3987103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN42G91DIOtherBCBS CLINIC NUMBER
MN42G92DIOtherPROVIDER PIN