Provider Demographics
NPI:1992036693
Name:DIETRICH, SALLIE (MS)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:
Last Name:DIETRICH
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 1:905 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7949
Mailing Address - Country:US
Mailing Address - Phone:918-787-2104
Mailing Address - Fax:918-787-2106
Practice Address - Street 1:905 E 3RD ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7949
Practice Address - Country:US
Practice Address - Phone:918-787-2104
Practice Address - Fax:918-787-2106
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731013488Medicaid