MEDICARE: MCKENNA DIETZE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1205727104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENNA DIETZE

Provider Business Mailing Address
First Line	:	365 N HONEY CREEK PKWY APT 300
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53213-3484
Country	:	US
Telephone Number	:	414-458-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	365 N HONEY CREEK PKWY APT 300
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53213-3484
Country	:	US
Telephone Number	:	414-458-1111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2025
Last Update Date	:	07/10/2025

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Directions to “ MCKENNA DIETZE ” Practice Location

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