Healthcare Provider Details

I. General information

NPI: 1851961734
Provider Name (Legal Business Name): SKYLER DIETZMAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SKYLER MAKKINJE LCSW

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1966 MAPLE ST APT 4
HOPKINTON NH
03229-3315
US

IV. Provider business mailing address

PO BOX 1730
HILLSBORO NH
03244-1730
US

V. Phone/Fax

Practice location:
  • Phone: 719-641-8860
  • Fax:
Mailing address:
  • Phone: 719-641-8860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW18419
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSW18419
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: