Provider Demographics
NPI:1336563360
Name:DIETZ, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DIETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 S WOOD DALE RD APT 203
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-2262
Mailing Address - Country:US
Mailing Address - Phone:847-513-2786
Mailing Address - Fax:
Practice Address - Street 1:190 S WOOD DALE RD APT 203
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-2262
Practice Address - Country:US
Practice Address - Phone:847-513-2786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst