Provider Demographics
NPI:1649838020
Name:DIETRICK, CONSTANCE (LCSW)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:DIETRICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 FOREST PARK AVE STE 1210
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2212
Mailing Address - Country:US
Mailing Address - Phone:314-286-1940
Mailing Address - Fax:314-286-1473
Practice Address - Street 1:4455 DUNCAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1111
Practice Address - Country:US
Practice Address - Phone:314-286-1940
Practice Address - Fax:314-286-1473
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0047521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical