Provider Demographics
NPI:1023644465
Name:DIETERT, KRISTEN M (CRC)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:M
Last Name:DIETERT
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 HUNTING HORN WAY W
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4829
Mailing Address - Country:US
Mailing Address - Phone:585-474-6278
Mailing Address - Fax:
Practice Address - Street 1:927 HUNTING HORN WAY W
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4829
Practice Address - Country:US
Practice Address - Phone:585-474-6278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA946101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)