=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629324850
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JODY DIANE DIETSCH LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2012
-----------------------------------------------------
Last Update Date | 09/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 327 E WAYNE ST STE 100
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46802-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-786-5865
-----------------------------------------------------
Fax | 260-676-4686
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11109 PARKVIEW PLAZA DR # 117
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34004929A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------