Provider Demographics
NPI:1811458920
Name:DIETZ, KIM (LMT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-6852
Mailing Address - Country:US
Mailing Address - Phone:920-207-4440
Mailing Address - Fax:
Practice Address - Street 1:4027 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1261
Practice Address - Country:US
Practice Address - Phone:920-207-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14101146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist