Provider Demographics
NPI:1154425452
Name:DIETERLE, URSULA ANNA (PT)
Entity type:Individual
Prefix:
First Name:URSULA
Middle Name:ANNA
Last Name:DIETERLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 880
Mailing Address - Street 2:MISSION DRIVE
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:406-745-4233
Practice Address - Street 1:#8 MISSION DRIVE
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865
Practice Address - Country:US
Practice Address - Phone:406-745-2525
Practice Address - Fax:406-745-4233
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT394PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT03-01605-2OtherSTATE FUND
MT60416OtherBCBS
MT341598Medicaid
MT03-01605-2OtherSTATE FUND