Healthcare Provider Details

I. General information

NPI: 1609229640
Provider Name (Legal Business Name): KRISTEN YVONNE DIETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 TILLER WAY
ROSEVILLE CA
95747-6131
US

IV. Provider business mailing address

5050 TILLER WAY
ROSEVILLE CA
95747-6131
US

V. Phone/Fax

Practice location:
  • Phone: 714-290-6054
  • Fax:
Mailing address:
  • Phone: 714-290-6054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number73940
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: