MEDICARE: CHRISTINE DIETZ LCSW

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	101YM0800X	Mental Health Counselor	LC6618	ME
2	1041C0700X	Clinical Social Worker	LC6618	ME
3	1041C0700X	Clinical Social Worker	032904-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275645640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE DIETZ LCSW

Provider Business Mailing Address
First Line	:	1010 MAIN ST
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14202-1102
Country	:	US
Telephone Number	:	716-859-4726
Fax Number	:	716-859-4818

Provider Business Practice Location Address
First Line	:	1010 MAIN ST
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14202-1102
Country	:	US
Telephone Number	:	716-859-4726
Fax Number	:	716-859-4818

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	09/29/2010

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Directions to “ CHRISTINE DIETZ LCSW” Practice Location

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