Healthcare Provider Details

I. General information

NPI: 1841937703
Provider Name (Legal Business Name): REBEKAH DIETRICH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CENTURY PKWY STE 350
MOUNT LAUREL NJ
08054-1149
US

IV. Provider business mailing address

1000 CENTURY PKWY STE 350
MOUNT LAUREL NJ
08054-1145
US

V. Phone/Fax

Practice location:
  • Phone: 856-380-2400
  • Fax:
Mailing address:
  • Phone: 862-926-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MB13128800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: