Healthcare Provider Details

I. General information

NPI: 1790347342
Provider Name (Legal Business Name): MR. MATTHIAS A DIETRICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MONTGOMERY BLVD NE STE B101
ALBUQUERQUE NM
87109-1206
US

IV. Provider business mailing address

1405 RIDGECREST DR SE
ALBUQUERQUE NM
87108-4453
US

V. Phone/Fax

Practice location:
  • Phone: 505-300-2635
  • Fax:
Mailing address:
  • Phone: 505-363-2492
  • Fax: 505-266-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0224741
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: