Healthcare Provider Details

I. General information

NPI: 1376672667
Provider Name (Legal Business Name): MARY ANN DIETZEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4407 N DIVISION ST STE 505
SPOKANE WA
99207-1613
US

IV. Provider business mailing address

4407 N. DIVISION SUITE 505
SPOKANE WA
99207-1613
US

V. Phone/Fax

Practice location:
  • Phone: 509-487-9131
  • Fax: 509-482-9022
Mailing address:
  • Phone: 509-487-9131
  • Fax: 509-482-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1559
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: