Healthcare Provider Details

I. General information

NPI: 1003067919
Provider Name (Legal Business Name): MARCIA C DIEDERICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25250 N 35TH AVE
PHOENIX AZ
85083-4335
US

IV. Provider business mailing address

25250 N 35TH AVE
PHOENIX AZ
85083-4335
US

V. Phone/Fax

Practice location:
  • Phone: 623-445-7100
  • Fax: 623-445-7180
Mailing address:
  • Phone: 623-445-7100
  • Fax: 623-445-7180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4074924
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: