Healthcare Provider Details

I. General information

NPI: 1043712862
Provider Name (Legal Business Name): MATTHEW DIETZ PMHNP-BC, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 MENTOR AVE
MENTOR OH
44060-6412
US

IV. Provider business mailing address

9220 MENTOR AVE
MENTOR OH
44060-6412
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-1700
  • Fax: 877-242-9583
Mailing address:
  • Phone: 440-255-1700
  • Fax: 877-242-9583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number854944
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN394717
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP143192
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: