Provider Demographics
NPI:1336380484
Name:DIETERS, MICHAEL ALAN (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:DIETERS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4618
Mailing Address - Country:US
Mailing Address - Phone:307-220-3901
Mailing Address - Fax:307-369-4188
Practice Address - Street 1:516 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4618
Practice Address - Country:US
Practice Address - Phone:307-220-3901
Practice Address - Fax:307-369-4188
Is Sole Proprietor?:No
Enumeration Date:2009-03-19
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC 893101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional