Healthcare Provider Details

I. General information

NPI: 1518450212
Provider Name (Legal Business Name): BRAD WILLIAM DIETRICH JR. LISW, I.2506324
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 S MAIN ST
LIMA OH
45804-1519
US

IV. Provider business mailing address

338 PONDEROSA LN
LIMA OH
45805-3964
US

V. Phone/Fax

Practice location:
  • Phone: 419-229-2222
  • Fax:
Mailing address:
  • Phone: 419-860-4470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2506324
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: