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General NPI Number Information
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NPI Number | 1700924800
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Entity Type | Individual
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Provider Name | SUSAN J RAUTIO-DIETZ PH.D.
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Gender | Female
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 532 N WALNUT ST SUITE D
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City | BLOOMINGTON
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State | IN
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Zip | 47404-3809
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Country | US
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Telephone | 812-332-7394
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5185
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City | BLOOMINGTON
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State | IN
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Zip | 47407-5185
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20040224A
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License Number State | IN
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