Provider Demographics
NPI:1518450212
Name:DIETRICH, BRAD WILLIAM JR (LISW, I2506324)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:WILLIAM
Last Name:DIETRICH
Suffix:JR
Gender:M
Credentials:LISW, I2506324
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3964
Mailing Address - Country:US
Mailing Address - Phone:419-860-4470
Mailing Address - Fax:
Practice Address - Street 1:799 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1519
Practice Address - Country:US
Practice Address - Phone:419-229-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.25063241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical