Provider Demographics
NPI:1700924800
Name:RAUTIO-DIETZ, SUSAN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:RAUTIO-DIETZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:RAUTIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5185
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407-5185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:532 N WALNUT ST
Practice Address - Street 2:SUITE D
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3809
Practice Address - Country:US
Practice Address - Phone:812-332-7394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040224A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist