Healthcare Provider Details

I. General information

NPI: 1992969224
Provider Name (Legal Business Name): DAVID ROBERT DIETRICH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 PURDY ST
BIRMINGHAM MI
48009-1738
US

IV. Provider business mailing address

625 PURDY ST
BIRMINGHAM MI
48009-1738
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6515
  • Fax: 248-646-2760
Mailing address:
  • Phone: 248-646-6515
  • Fax: 248-646-2760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number6301003061
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: