Healthcare Provider Details

I. General information

NPI: 1962986455
Provider Name (Legal Business Name): BRAD S DIETER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 STARR AVE
TOLEDO OH
43605-2456
US

IV. Provider business mailing address

1425 STARR AVE
TOLEDO OH
43605-2456
US

V. Phone/Fax

Practice location:
  • Phone: 419-936-7600
  • Fax: 419-936-7606
Mailing address:
  • Phone: 419-936-7600
  • Fax: 419-936-7606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2102532
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: