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NPI Code Detail

MEDICARE: CARLY RAE DIETZ M.A.

MEDICARE: CARLY RAE DIETZ M.A.
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
1101Y00000XCounselor

General Provider Information

NPI Number : 1235202656
Entity Type Code : Individual
Provider Name (Legal Business Name) : CARLY RAE DIETZ M.A.
Provider Business Mailing Address
First Line : 1517 GOLDEN GATE AVE
Second Line :
City : SAN FRANCISCO
State : CA
Zip : 94115-4514
Country : US
Telephone Number : 415-572-1763
Fax Number :
Provider Business Practice Location Address
First Line : 2513 24TH ST
Second Line :
City : SAN FRANCISCO
State : CA
Zip : 94110-3556
Country : US
Telephone Number : 415-264-8205
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/15/2006
Last Update Date : 07/08/2007

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