Provider Demographics
NPI:1356398382
Name:DIETRICH, MONICA L (MPT)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:L
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17134 BEL RAY PL
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-5331
Mailing Address - Country:US
Mailing Address - Phone:816-226-4011
Mailing Address - Fax:816-524-6115
Practice Address - Street 1:6640 JOHNSON DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-2617
Practice Address - Country:US
Practice Address - Phone:913-384-5600
Practice Address - Fax:913-384-0719
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02977225100000X
MO2001010961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
28353043OtherBCBS KC
KSKA2868017OtherMEDICARE PTAN
MOMA4370011OtherMEDICARE PTAN
MO28353033OtherBLUE CROSS BLUE SHIELD - MO