Provider Demographics
NPI:1891448163
Name:DIETRICH, ALLISON BLAIR
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:BLAIR
Last Name:DIETRICH
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 1:4208 RIDGLEA COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-2224
Mailing Address - Country:US
Mailing Address - Phone:817-703-1680
Mailing Address - Fax:
Practice Address - Street 1:4208 RIDGLEA COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-2224
Practice Address - Country:US
Practice Address - Phone:817-703-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68145101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional