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NPI Code Detail

MEDICARE: BRIDGET DIETZ LCSW

MEDICARE: BRIDGET 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
1104100000XSocial Worker05707KS
2104100000XSocial Worker10209KS
3104100000XSocial Worker2016041300MO
41041C0700XClinical Social Worker149024574IL

General Provider Information

NPI Number : 1720522592
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIDGET DIETZ LCSW
Provider Business Mailing Address
First Line : 4707 N BROADWAY ST STE 200
Second Line :
City : CHICAGO
State : IL
Zip : 60640-4999
Country : US
Telephone Number : 312-971-9441
Fax Number :
Provider Business Practice Location Address
First Line : 4707 N BROADWAY ST STE 200
Second Line :
City : CHICAGO
State : IL
Zip : 60640-4999
Country : US
Telephone Number : 312-971-9441
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/13/2016
Last Update Date : 08/12/2024

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Directions to “ BRIDGET DIETZ LCSW” Practice Location

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