Provider Demographics
NPI:1851426753
Name:DIETZMAN, STEVEN TODD (LAT)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:TODD
Last Name:DIETZMAN
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-8100
Mailing Address - Fax:715-848-8199
Practice Address - Street 1:103 SOUTH GIBSON STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451
Practice Address - Country:US
Practice Address - Phone:715-748-8112
Practice Address - Fax:715-748-8792
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI197-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer