Provider Demographics
NPI:1245947670
Name:DETTLOFF, DIANE JO
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:JO
Last Name:DETTLOFF
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 1:35815 ROAD P.5
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328-8798
Mailing Address - Country:US
Mailing Address - Phone:970-570-9673
Mailing Address - Fax:
Practice Address - Street 1:35815 ROAD P.5
Practice Address - Street 2:
Practice Address - City:MANCOS
Practice Address - State:CO
Practice Address - Zip Code:81328-8798
Practice Address - Country:US
Practice Address - Phone:970-570-9673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099255691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical