Healthcare Provider Details

I. General information

NPI: 1326163486
Provider Name (Legal Business Name): MR. CHARLES EDWARD DIETZEL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CHARLES EDWARD DIETZEL JR. LCPC

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 HANCOCK AVE
HIRAM ME
04041
US

IV. Provider business mailing address

36 HANDCOC AVE.
HIRAM ME
04041
US

V. Phone/Fax

Practice location:
  • Phone: 207-625-8947
  • Fax:
Mailing address:
  • Phone: 207-625-8947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: