Healthcare Provider Details

I. General information

NPI: 1316335110
Provider Name (Legal Business Name): MEREDITH DIETRICH L.M.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2590 FRISBY AVE
BRONX NY
10461-3240
US

IV. Provider business mailing address

315 E 77TH ST 3F
NEW YORK NY
10075-2251
US

V. Phone/Fax

Practice location:
  • Phone: 718-239-1610
  • Fax:
Mailing address:
  • Phone: 310-614-3675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091138-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: