=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205763133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLIN J DIETRICK LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2026
-----------------------------------------------------
Last Update Date | 05/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21651 E COUNTRY VISTA DR STE F
-----------------------------------------------------
City | LIBERTY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99019-7709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 298-610-5122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S WOODRUFF RD APT A302
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99206-3797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-610-5122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MASS.MA.70085923
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------