Provider Demographics
NPI:1548287071
Name:DIETRICH, CAROL A (MSW)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:A
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S CHURCH STREET
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5414
Mailing Address - Country:US
Mailing Address - Phone:410-848-9244
Mailing Address - Fax:410-876-5042
Practice Address - Street 1:40 S CHURCH STREET
Practice Address - Street 2:SUITE 105
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5414
Practice Address - Country:US
Practice Address - Phone:410-848-9244
Practice Address - Fax:410-876-5042
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD027081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDZ16901100Medicaid
MDZ16901100Medicaid
MDQY31Medicare ID - Type Unspecified