Provider Demographics
NPI:1902240864
Name:DIETRICH, STACEY (MA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CHILDRENS WAY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8135
Mailing Address - Country:US
Mailing Address - Phone:386-668-4774
Mailing Address - Fax:386-668-4486
Practice Address - Street 1:51 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:FL
Practice Address - Zip Code:32725-8135
Practice Address - Country:US
Practice Address - Phone:386-668-4774
Practice Address - Fax:386-668-4486
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health