Provider Demographics
NPI:1952438293
Name:DIETZ, LISA DIANE (MS)
Entity type:Individual
Prefix:MR
First Name:LISA
Middle Name:DIANE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:222 E GRAND AVE
Mailing Address - Street 2:SUITE 404
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4316
Mailing Address - Country:US
Mailing Address - Phone:580-763-2256
Mailing Address - Fax:580-762-6511
Practice Address - Street 1:222 E GRAND AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4316
Practice Address - Country:US
Practice Address - Phone:580-763-2256
Practice Address - Fax:580-762-6511
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1642101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health