Provider Demographics
NPI:1669896031
Name:DIETZ, DAVID (OTR/L)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DIETZ
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-3138
Mailing Address - Country:US
Mailing Address - Phone:773-716-4725
Mailing Address - Fax:
Practice Address - Street 1:124 WINDSOR PARK DR
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-1986
Practice Address - Country:US
Practice Address - Phone:630-510-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008407225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist