Provider Demographics
NPI:1457609471
Name:DIETSCH, BRYAN (DPT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:DIETSCH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7157 JAMESFORD DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1370
Mailing Address - Country:US
Mailing Address - Phone:419-410-2876
Mailing Address - Fax:
Practice Address - Street 1:5855 MONROE ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2269
Practice Address - Country:US
Practice Address - Phone:419-291-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-23
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist