Provider Demographics
NPI:1972254076
Name:DIETERICH, ADDISON GRACE (MS)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:GRACE
Last Name:DIETERICH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 WINDIGROVE DR APT 633
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-7593
Mailing Address - Country:US
Mailing Address - Phone:703-324-6357
Mailing Address - Fax:
Practice Address - Street 1:5974 JARMANS GAP RD
Practice Address - Street 2:
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-3340
Practice Address - Country:US
Practice Address - Phone:434-202-4080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0730000609106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist