Healthcare Provider Details

I. General information

NPI: 1245150655
Provider Name (Legal Business Name): FIRESIDE PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N ST STE 102
ANCHORAGE AK
99501-3285
US

IV. Provider business mailing address

821 N ST STE 102
ANCHORAGE AK
99501-3285
US

V. Phone/Fax

Practice location:
  • Phone: 909-488-0785
  • Fax:
Mailing address:
  • Phone: 909-488-0785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MOLLY DIETRICH
Title or Position: OWNER
Credential: PSYD
Phone: 909-488-0785