MEDICARE: COLLIN J DIETRICK LMT

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	225700000X	Massage Therapist	MASS.MA.70085923	WA

General Provider Information

NPI Number	:	1205763133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN J DIETRICK LMT

Provider Business Mailing Address
First Line	:	601 S WOODRUFF RD APT A302
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-3797
Country	:	US
Telephone Number	:	208-610-5122
Fax Number	:

Provider Business Practice Location Address
First Line	:	21651 E COUNTRY VISTA DR STE F
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-7709
Country	:	US
Telephone Number	:	298-610-5122
Fax Number	:

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

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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