MEDICARE: STEPHANIE MARIE DILTZ CDP, LICSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP60253597	WA
2	1041C0700X	Clinical Social Worker	LW60996164	WA

General Provider Information

NPI Number	:	1730491424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MARIE DILTZ CDP, LICSW

Provider Business Mailing Address
First Line	:	908 GEORGIANA ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-3912
Country	:	US
Telephone Number	:	360-504-3731
Fax Number	:	360-504-3984

Provider Business Practice Location Address
First Line	:	908 GEORGIANA ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-3912
Country	:	US
Telephone Number	:	360-504-3731
Fax Number	:	360-504-3984

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

Provider Enumeration Date	:	07/09/2010
Last Update Date	:	12/06/2021

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