Provider Demographics
NPI:1356360812
Name:DIETRICH, BRIAN DAMIEN (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAMIEN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-564-9464
Mailing Address - Fax:415-507-4114
Practice Address - Street 1:1531 PURDUE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-564-9464
Practice Address - Fax:415-507-4114
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT36493106H00000X
CALMFT36493106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist