Provider Demographics
NPI:1396976890
Name:DIETSCH, RYAN (LCPC)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:DIETSCH
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S CLINTON ST
Mailing Address - Street 2:MAILSTOP CT 05-13
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5730
Mailing Address - Country:US
Mailing Address - Phone:443-890-3397
Mailing Address - Fax:
Practice Address - Street 1:1501 S CLINTON ST
Practice Address - Street 2:MAILSTOP 05-13
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224
Practice Address - Country:US
Practice Address - Phone:443-890-3397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7221101YM0800X, 101YP2500X
MDLCPC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional